Based on observations, record review and interview, the facility failed to develop an acute/baseline care plan for one (#51) of two residents reviewed for care planning out of 46 sample residents. Specifically, the facility failed to include Resident #51's seatbelt use on the baseline care plan.Findings include:I. Facility policy and procedureThe Person Centered Care Planning policy and procedure, reviewed 8/29/25, was retrieved from the executive director on 5/15/26 at 12:23 p.m. It read in pertinent part, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. …
F655 citations in Colorado
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F655 less often than its own record predicts
0.85 times the national share — cited less often here than elsewhere.
Of every deficiency written in Colorado in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F655 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 | 0.25% | 0.32× |
| 2024 | 0.22% | 0.33× |
| 2025 | 0.56% | 0.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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