Based on record review and interviews, the facility failed to revise the care plan for one resident (#1) out of three residents reviewed, to reflect, respond, and alert staff to the resident's behaviors that placed Resident #3 and others at risk for harm. Record review revealed on 10/13/23 at approximately 5:30 a.m., a certified nurse aide (CNA) entered Resident #1's room and found Resident #1 sitting in his chair next to the bed of his roommate, Resident #3. Resident #1 was holding a foot pedal to his wheelchair and his roommate had injuries to his face and body. Further record review revealed two days earlier, on 10/11/23, Resident #1 had transferred to the memory unit and into a room with Resident #3 who used a continuous positive airway pressure (CPAP) machine and oxygen at night. …
F657 citations in Colorado
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F657 less often than its own record predicts
0.06 times the national share — cited less often here than elsewhere.
Of every deficiency written in Colorado in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F657 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.
Based on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and personalized care for six (#9, #83, #104, #41, #2 and #29) of 10 residents out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #9's and Resident #83's care plans were updated with catheter care interventions;-Ensure Resident #104's care plan was updated with skin integrity/pressure wound interventions and feeding precaution interventions; -Ensure Resident #41's dementia and behavioral care plan was updated with all appropriate non-pharmacological interventions for psychotropic medications;-Ensure Resident #2's care plan was updated with specific target behaviors and… …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.51% | 0.24× |
| 2024 | 0.45% | 0.23× |
| 2025 | 0.11% | 0.06× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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