Based on record review and staff interviews, the facility failed to coordinate a resident review with the Preadmission Screening and Resident Review (PASARR) program under Medicaid by not referring a resident that expressed suicidal ideations on admission for a significant change in status assessment for review by the State Designated Authority for one (1) of seven (7) residents sampled. Resident #1. During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. …
F644 · 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.
Every F644 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F644 finding.
The harm level
How severely F644 is cited
0.2% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J10.0% | K— | L— |
| Actual harm | G40.1% | H— | I— |
| No harm, potential for more than minimal | D2,41588.4% | E28010.2% | F70.3% |
| No harm, potential for minimal | A— | B240.9% | C10.0% |
In the surveyor’s words
What an F644 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
.Based on record review and interview, the facility failed to comply with PASRR Pre-admission Screening and Resident Review - requirements by not incorporating the PASRR Level II determination into the resident's assessment, care planning, and discharge planning for 1 Resident (#113), out of one resident reviewed for PASRR documentation. The PASRR Level II evaluation identified the need for continued nursing facility services and required specialized mental health services. The facility did not ensure the Level II report was available at admission, did not initiate specialized services during the stay, did not revise the care plan to reflect PASRR findings, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. …
Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program. for 3 of 15 (Residents #40, #10 and #23) residents reviewed for PASARR: 1.Resident #40 had a negative PASARR level 1 on admission and did not include form 1012 from physician. 2. Resident #10 had a negative PASARR level 1 on admission, should be positive PL1. 3. Resident #23's recommendation of Therapy services were not completed. This failure could place residents at risk of not receiving specialized services and could result in loss of PASARR services. …
Based on review of clinical record, review of facility policy, and interviews for 1 of 5 sampled residents (Resident #45) reviewed for pre-admission screening and resident review (PASARR), the facility failed to ensure a referral to the entity responsible for conducting level II PASARR screening was made for a resident with a new qualifying psychiatric diagnosis. The findings include:Resident #45's diagnoses included bipolar disorder, anxiety disorder, mood disorder, and adjustment disorder. The quarterly MDS assessment dated [DATE] identified Resident #45 was moderately cognitively impaired with no identified behaviors, required maximal assistance with transfers and utilized a wheelchair for mobility. …
By state — 2025
Where F644 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- West Virginia3.70× · 26 citations
- Louisiana2.81× · 38 citations
- Iowa2.45× · 37 citations
- Texas1.91× · 117 citations
- North Carolina1.89× · 25 citations
- Washington1.43× · 26 citations
- Ohio1.29× · 53 citations
- Florida1.28× · 25 citations
- Illinois1.27× · 54 citations
- California0.67× · 67 citations
Co-occurrence
Cited alongside F644
Of the 2025 surveys that cited F644, these tags appeared in the same inspection more often than chance would predict.
- F7915.8% of F644 surveys · 5.0× chance
Provide or obtain dental services for each resident.
- F64512.4% of F644 surveys · 4.9× chance
PASARR screening for Mental disorders or Intellectual Disabilities
- F6995.4% of F644 surveys · 3.9× chance
Provide care or services that was trauma informed and/or culturally competent.
- F7589.4% of F644 surveys · 3.6× chance
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- F8146.4% of F644 surveys · 3.5× chance
Dispose of garbage and refuse properly.
Cited in the same inspection, not caused by one another.
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