US
U.S. Department of Health and Human Services, Office of Inspector General
Published February 2024

Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements For Life Safety, Emergency Preparedness, And Infection Control

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Overall Conclusion

Colorado could better ensure that nursing homes participating in Medicare and Medicaid comply with Federal life safety, emergency preparedness, and infection control requirements. Deficiencies were observed across all 20 nursing homes audited, indicating ongoing oversight challenges and the need for stronger follow-up actions and staff training.

Source Document

Audit Scope

As of July 2022, 219 nursing homes in Colorado participated in the Medicare or Medicaid programs. A nonstatistical sample of 20 nursing homes was selected for audit based on location and risk factors; unannounced site visits were conducted September–November 2022 to assess compliance with life safety, emergency preparedness, and infection control requirements per CMS survey checklists.

Key Findings Summary

1

Deficiencies were identified at all 20 nursing homes audited, totaling 556 deficiencies (165 life safety; 210 emergency preparedness; 181 infection control).

2

Deficiencies occurred due to inadequate oversight by the State agency and nursing home management, frequent turnover, and limited survey resources, contributing to a backlog.

3

CDPHE had a backlog of standard surveys; 38 of 219 Medicare- and Medicaid-certified nursing homes in Colorado had not had a standard survey conducted since the resumption of these surveys, as of the draft report.

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AI-Assisted

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AI Scope Summary

Future audits should assess whether the state agency maintains an effective, risk-based survey program to ensure CMS life safety, emergency preparedness, and infection control requirements are met, focusing on survey cadence, backlog reduction, corrective action follow-up, and staff training improvements across nursing homes with a history of high-risk deficiencies or turnover.

AI-Generated Insight

The audit highlights continued gaps in oversight and resources for state survey agencies, resulting in widespread deficiencies across life safety, emergency preparedness, and infection control in Colorado nursing homes. The findings support prioritizing risk-based surveys and standardized staff training to improve resident safety.