Based on observation, interview and record review, the facility failed to ensure a resident with a positive Pre-admission Screening and Resident Review (PASRR) Level II evaluation ensured recommendations from a Positive Behavioral Support Plan was implemented and incorporated into the plan of care for 1 of 1 (4) residents reviewed for PASRR evaluations. This failure to ensure a behavioral support plan was implemented caused harm to Resident 4 who experienced plaque build up, bleeding and irritated gums, oral pain and the dentist would not repair a broken bridge until Resident 4 exhibited good oral hygiene which had the potential to impact the resident's sense of self. Findings included: Resident 4 was a long-term care resident with [DIAGNOSES REDACTED]. …
F645 citations in Washington
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
Washington cites F645 more often than its own record predicts
4.66 times the share F645 takes of citations nationally.
Of every deficiency written in Washington 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 Washington surveyors wrote
F645 findings written in Washington, 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 Pre-admission Screening and Resident Reviews (PASRR, a screening tool used to identify behavioral healthcare needs) were completed for 3 of 4 residents (1, 10, & 11) reviewed for PASRR. This failure placed residents at risk for inappropriate placement, unmet behavioral healthcare needs and diminished quality of life.Findings included. Resident 1 Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs). Level 1 PASRR Review, dated 07/06/2026, documented Resident 1 had a mood disorder and exhibited functional limitations related to a behavioral health disorder. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 1.46% | 2.50× |
| 2024 | 2.13% | 3.33× |
| 2025 | 2.83% | 4.66× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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