Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for three (#106, #37 and #10) of six residents reviewed for accident hazards out of 42 sample residents.Specifically, the facility failed to:-Ensure Resident #106 was transported appropriately in the facility transportation vehicle, which resulted in a fall from the resident's wheelchair causing fractures to both of her lower extremities;-Ensure Resident #37's care planned fall interventions were consistently implemented by staff in order to prevent multiple falls for the resident, including one with major injury; and,-Ensure the interdisciplinary team (IDT) reviewed Resident #37 and Resident #10's falls in a timely manner in order to determine if the… …
F689 citations in Colorado
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F689 more often than its own record predicts
1.60 times the share F689 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F689 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 observations, record review and interviews, the facility failed to ensure three (#13, #2 and #35) of six residents reviewed for accidents out of 26 sample residents received adequate supervision to prevent accidents. Resident #13 was admitted on [DATE] with a diagnosis of dementia. Resident #13 was identified as a high fall risk. On 8/23/26 at approximately 4:27 a.m. Resident #13 awakened and a motion sensor in her room alerted certified nurse aide (CNA) #5 of Resident #13's movement. CNA #5 recognized that Resident #13 was restless, but did not assist the resident to the restroom at the time, which was a care planned fall intervention for the resident. …
Based on observations, record review and interviews, the facility failed to ensure one (#5) of three residents reviewed for accidents out of seven sample residents remained as free from accidents and hazards as possible.Specifically, the facility failed to: -Ensure staff implemented care planned fall interventions to prevent a fall for Resident #5;-Implement new fall interventions in a timely manner for Resident #5 following a fall on 8/14/26;-Ensure staff documented in the electronic medical record (EMR) a fall for Resident #5, including documentation of neurological assessments and ongoing monitoring following the fall on 8/14/26; and,-Ensure staff documented in the EMR notification to Resident #5's representative of the resident's fall and documented notification regarding the… …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 6.60% | 1.34× |
| 2024 | 5.16% | 0.96× |
| 2025 | 8.86% | 1.60× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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