Based on record review and interview the facility failed to ensure a notice of Resident 1 fall on [DATE] was sent to Resident 1's physician. Resident 1 died in facility on [DATE]. The facility census was 59. Findings are: Record review of Resident 1's Progress Notes dated [DATE] at revealed Resident 1 had a fall from the wheelchair at the nurse's station on [DATE] at 8:30AM. The resident was assisted to wheelchair and back to bed. Vital signs were obtained. No injuries were noted. Record review of Vital signs dated [DATE] at 12:16PM revealed temperature of 97.3, Pulse 73, Blood Pressure ,d+[DATE], respirations 16 and oxygen saturation 90%. Record review of vital signs logs dated [DATE] -[DATE] revealed that only one 1 set of vital signs was obtained on [DATE]. …
F646
Resident Assessment and Care Planning Deficiencies
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F646 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F646 finding.
The harm level
How severely F646 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D22893.1% | E124.9% | F— |
| No harm, potential for minimal | A— | B52.0% | C— |
In the surveyor’s words
What an F646 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 interview and record review the facility failed to ensure a nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for 1 of 8 (Resident #8) residents reviewed for PASARR services in that:Resident #8 was positive for PASARR services, but the PASARR staff were not notified of the significant change of a feeding tube. …
Based on interview and record review, the facility failed to notify the state mental health authority coordinator of a significant change in physical condition, for 1 of 5 residents (Resident 25) reviewed for PASRR process (Preadmission Screening and Resident Review, a screening tool used to identify mental health needs). This failure placed the residents at risk for unmet care and a diminished quality of life. Findings included. Resident 25 was admitted to the facility on [DATE], with multiple diagnosis to include Depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in daily activities). …
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