Based on interview and record review the facility failed to confirm that the Pre-admission Screening and Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation for 1 resident (Resident #2) of one reviewed. Findings include: Review of the clinical record revealed Resident #2 (R2) was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included anxiety, major depression and unspecified dementia. The Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 6/05/26 revealed R2 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). …
F645 citations in Michigan
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
Michigan cites F645 more often than its own record predicts
1.05 times the share F645 takes of citations nationally.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F645 findings written in Michigan, 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 interview and record review, the facility failed to ensure a level two assessment was completed or exemption criteria was documented for one sampled resident (R11) of one reviewed for Preadmission screening/Annual Resident Review/Mental Illness/Intellectual Disability/Related Conditions Identification (PAS/ARR) requirements, resulting in the potential for resident care needs to not be fully met. Findings include: On 11/08/18 at 9:59 AM the clinical record for R11 was reviewed and revealed, a Level 1 PAS/ARR form 3877 dated 02/28/18 which had 'Yes' checked for the first three items in Section two. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.75% | 1.28× |
| 2024 | 0.90% | 1.41× |
| 2025 | 0.64% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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