Based on record review and interviews, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#39) of two residents reviewed for PASRR out of 38 sample residents.Specifically, the facility failed to arrange and incorporate recommendations from the PASRR Level II notice of determination (NOD) for Resident #39. Findings include:I. Facility policy and procedureThe PASRR policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 12/18/25 at 6:11 p.m. …
F644 citations in Colorado
PASARR coordination · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F644 more often than its own record predicts
1.05 times the share F644 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F644.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F644 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 | 0.93% | 1.30× |
| 2024 | 0.67% | 1.05× |
| 2025 | 0.67% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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