Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
F837 in Colorado. Pick another state for the same tag.
No F837 citations were recorded in Colorado for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Colorado surveyors wrote
F837 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.
G · Actual harm, isolatedApril 19, 2022
Based on record review and interviews, the governing body failed to implement policies regarding the management and operations of the facility.
Specifically, the facility failed to ensure the governing body was providing effective oversight to the facility to ensure the facility was in compliance with state and federal regulations.
Findings include:
I. Facility policy
The Quality Assurance and Performance Improvement (QAPI) practice guide was received from the assistant nursing home administrator from a sister facility on 4/21/22. The policy read in pertinent part, The governing body assures the QAPI program is adequately resourced to conduct its work. …
F · No harm, potential for more than minimal, widespreadNovember 29, 2022
Based on record review and interviews, the facility's governing body failed to appoint an administrator who was licensed by the State.
Specifically, the facility failed to ensure the temporary nursing home administrator license was valid and did not expire.
Findings include:
I. Entrance interview
On 11/29/22 at 10:45 a.m. the entrance conference was conducted with the director of nursing (DON). The DON was acting as the nursing facility's administrator (NHA) at the time of the survey and the facility had active job listings posted for a permanent licensed nursing home administrator.
II. Record review
On 11/29/22 at 10:50 a.m. a review was conducted on the State licensing website. The website showed the DON had not applied for a temporary NHA license for emergency situations.
III. …
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