Based on interviews and record review, the facility failed to have sufficient staff with the appropriate competencies on unit 2 (Elk Run) to ensure the residents attained and maintained their highest practicable physical, mental and psychosocial well-being, given their need for services. (Cross-reference F600, F686, and F838) This deficiency was cited previously during a complaint survey 12/21/18. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance and the scope and severity of the deficiency has increased to a level of immediate jeopardy for serious harm. …
F725 citations in Colorado
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F725 less often than its own record predicts
0.14 times the national share — cited less often here than elsewhere.
Of every deficiency written in Colorado in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F725 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, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility failed to provide services and treatment to prevent multiple areas of concern including that resulted in actual harm; abuse prevention, accident prevention, identifying residents who had changes in health conditions so they could receive proper treatment, ensure wound care was provided, and daily… …
Based on observations, record review and interviews, the facility failed to provide sufficient nursing staff to ensure the resident received the care and services they required in a timely manner. Specifically, the facility failed to ensure residents received their showers as scheduled and call lights were answered in a timely manner for residents dependent on staff for their care. Findings include:I. Facility policy and procedureThe Staffing policy and procedure, revised 3/9/21, was provided by the nursing home administrator (NHA) on 3/12/26 at 5:42 p.m. It read in pertinent part, The facility maintains adequate staff on each shift to meet residents' needs. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.68% | 0.84× |
| 2024 | 0.15% | 0.19× |
| 2025 | 0.11% | 0.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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