Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) reevaluation after a significant change in physical or mental status was identified for a resident previously determined to have a Level II PASRR. This deficient practice affected 1 of 2 sampled residents reviewed for PASRR (Resident #90).Findings included:Resident #90 was admitted to the facility on [DATE]. Her cumulative diagnoses included anxiety disorder, bipolar disorder, depression, and Post-traumatic Stress Disorder (PTSD).A PASRR Level II Determination Letter dated 12/08/23 revealed Resident #90 had a Level II PASRR with no effective date and nursing facility placement was appropriate.A significant change in status Minimum Data Set… …
F646 citations in North Carolina
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
North Carolina cites F646 more often than its own record predicts
2.94 times the share F646 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F646 findings written in North Carolina, 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 North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.14% | 2.93× |
| 2024 | 0.08% | 1.70× |
| 2025 | 0.19% | 2.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction