F656 in Colorado. Pick another state for the same tag.
Against expectation — 2025
Colorado cites F656 less often than its own record predicts
Versus expected share0.13×
0.13 times the national share — cited less often here than elsewhere.
Share of Colorado citations0.45%
Of every deficiency written in Colorado in 2025, this is the portion that was F656.
Colorado0.45%
National3.45%
Share of all citations that were F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F656 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, isolatedJune 28, 2018
Based on record review and interview it was determined the facility failed to implement fall care plan interventions for one (1) resident from 23 sampled residents. On 5/14/18 one (1) staff person attempted to provide Resident #78 with incontinence care and bed mobility. The resident rolled from the bed, fell to the floor, sustaining facial injuries, a laceration to the forehead, and a [MEDICAL CONDITION] cervical vertebrae. The facility's failure to ensure the care plan developed to address Resident #78's limited bed mobility to promote safety resulted in an adverse outcome for the resident that constituted actual harm.
The findings include:
Resident #78 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. …
D · No harm, potential for more than minimal, isolatedJuly 30, 2026
Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two (#7 and #13) of seven residents reviewed for care plans out of 34 sample residents.Specifically, the facility failed to:-Develop and implement a person-centered comprehensive care plan which included Resident #7's use of antipsychotic medications; and,-Develop and implement a person-centered comprehensive care plan which included Resident #13's oxygen use.
Findings include:
I. Facility policy and procedure
The Comprehensive Care Plans and Revisions policy, revised August 2025, was provided by the nursing home administrator (NHA) on 8/4/26 at 10:40 a.m. …
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