Based on record review, review of the policy titled Preadmission Screening and Resident Review (PASARR) Policy, and staff interviews, the facility failed to follow through with recommendations for Level II PASARR for evaluation and determination for specialized services for one of 16 sampled residents (R)(R#1), who experienced worsening behaviors and had a known history of wrapping the call light, linen, and curtains around their body. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 3:50 p.m. …
F645 citations in Georgia
PASARR screening · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F645 more often than its own record predicts
1.51 times the share F645 takes of citations nationally.
Of every deficiency written in Georgia in 2025, this is the portion that was F645.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F645 findings written in Georgia, 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, staff interviews, and review of the facility policy titled, PASARR the facility failed to ensure one of one resident (R)71 reviewed for Preadmission Screening and Resident Review (PASARR) level two, actually received a level two screening. Findings include:Review of the facility policy titled, Resident Assessment - Coordination with PASARR Program with a reviewed/revised date of 03/1/2025 documented, Policy: The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.Review of the electronic medical record (EMR) revealed… …
Based on review of the medical records and staff and resident interviews, the facility failed to ensure the need of a PreAdmission Screening/Resident Review (PASARR) to ensure that individualized care and services were offered to meet residents' needs for three of 10 sampled residents (R) (R#62, R#51, R#53,) that were reviewed for PASARR. Findings include: 1.Review of medical record for R# 62 revealed [DIAGNOSES REDACTED]. Further review of the medical record indicated the following behaviors: On 7/16/19 at 5:13 p.m. R#62 was documented as initiating a physical altercation with another resident in which the other resident was hit in the mouth causing a tooth to dislodge. This ultimately resulted in a behavioral hospital stay. 1. On 1/13/19 at 12:25 a.m. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 1.70% | 2.92× |
| 2024 | 1.14% | 1.79× |
| 2025 | 0.91% | 1.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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