Based on record review and interview, it was determined that for one (R1) out of nine residents reviewed for resident rights, the facility failed to initiate a PASARR (Pre-admission Screening and Resident Review) review when R1 was started on a new anti-psychotic medication. Findings include:7/5/23 - R1's PASARR determined that R1 required a PASARR level II without specialized services. 7/7/23 - R1 admitted to the facility with a diagnoses, including but was not limited to, bipolar disorder.1/19/24 - Delusional disorder was added to R1's diagnoses list as evidenced by dates on R1's facility facesheet.This diagnosis was not documented on R1's 7/5/23 PASARR evaluation.3/6/25 - C1 (psychiatrist) documented in R1's progress notes, .Patient on Zyprexa (olanzapine) for off-label use was… …
F646 citations in Delaware
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.
Against expectation — 2025
Delaware cites F646 more often than its own record predicts
6.50 times the share F646 takes of citations nationally.
Of every deficiency written in Delaware in 2025, this is the portion that was F646.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F646 findings written in Delaware, 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.
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 0.53% | 10.74× |
| 2025 | 0.43% | 6.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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