IV. Resident #4 - The facility failed to initiate a thorough investigation of an injury of unknown origin. A. Resident #4 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included systemic involvement of connective tissue (autoimmune disease), arthritis, edema, and history of stroke. The 6/3/25 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 14 out of 15. The resident required total assistance (fully dependent) from the staff for toileting, dressing, bed mobility (the ability to sit up or roll from side to side while lying), and all transfers. The resident required (two-person) extensive assistance from the staff for bathing and personal hygiene. …
F610 citations in Colorado
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F610 more often than its own record predicts
1.19 times the share F610 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F610 findings written in Colorado, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interviews and record review, the facility failed to thoroughly and timely investigate an allegation of sexual abuse and protect one (#43) of two residents out of 30 sample residents during and after the investigation and, failed to investigate a subsequent allegation reported in resident council of staff's rough treatment. Resident #43 alleged sexual abuse by registered nurse (RN) #4 on 3/12/22. The facility failed to timely respond, thoroughly investigate and protect Resident #43, and allowed RN #4 to continue working with Resident #43. As a result, Resident #43 said she felt very upset and angry that she was not believed, and was fearful of RN #4. There was insufficient evidence the facility took measures to reassure Resident #43 and ensure she felt safe in her home. …
Based on observations, record review and interviews, the facility failed to have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the officials in accordance with State law, including to the State Survey Agency timely, for one of three allegations of abuse.Specifically, the facility failed to:-Conduct a thorough investigation of an allegation of sexual abuse by a staff member towards Resident #1 and submit a finalized investigation to the State Agency in the required time allotted; -Examine all available evidence and complete a root cause analysis of the evidence to prevent repeated incidents of Resident #1 alleging sexual abuse; and,-Assess other potential mental health factors affecting Resident #1's beliefs about sexual… …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.85% | 0.66× |
| 2024 | 1.05% | 0.73× |
| 2025 | 1.79% | 1.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction