F0641

E

Failure to Accurately Assess and Document Pressure Ulcer

Yarmouth, Maine Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The facility failed to accurately assess, coordinate care with a physician, and document a resident’s pressure-related wound. A nursing admission/readmission evaluation completed on the day of admission in November 2025 identified a skin issue on the resident’s left buttock that was described as pressure related. Daily Skilled Note/Evaluation entries on 11/30/25 and 12/7/25 documented that the resident’s skin was not intact and that there was a pressure ulcer on the left buttock. However, multiple subsequent Daily Skilled Note/Evaluation entries dated between 12/2/25 and 1/1/25 stated that the resident’s skin was intact, and a skin check note on 1/5/26 at 11:02 a.m. documented that no skin issues were identified.

On 1/5/25 at 2:06 p.m., a skin issue note documented that the resident had a stage 3 pressure ulcer/injury with full thickness skin loss. In an interview on 1/6/26, the Director of Nursing Services confirmed, in the presence of two surveyors, that the pressure ulcer had been present upon admission, was never thoroughly assessed, was not reported to a physician, and was not cared for appropriately.