Based on record review and interviews, the facility failed to notify the state mental health agency promptly after a significant change in the resident's mental condition for one (#7) of four residents out of 39 sample residents. Specifically, the facility failed to notify the state mental health agency authority of Resident #7's necessity for inpatient psychiatric hospitalization.Findings include:I. Facility Policy and ProcedureThe Pre-admission Screen and Resident Review (PASRR) policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 9/11/25 at 9:15 a.m. It revealed in pertinent part, If a resident's psychiatric status changes after admission. …
F646 citations in Colorado
Resident Assessment and Care Planning Deficiencies
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F646 more often than its own record predicts
1.71 times the share F646 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F646.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F646 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.
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 3.44× |
| 2024 | 0.07% | 1.60× |
| 2025 | 0.11% | 1.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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