F0655

D

Failure to Develop Baseline Care Plan for Resident With Pressure-Related Skin Issue

Yarmouth, Maine Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement a baseline care plan within 48 hours of admission that included necessary instructions for wound care for one resident. The resident was admitted in November 2025, and the Nursing Admission/Readmission Evaluation completed on the day of admission documented a pressure-related skin issue on the left buttock. Despite this identified pressure-related skin issue, review of the resident’s medical record showed no evidence of a baseline care plan addressing this condition or providing the instructions needed to properly care for it. On 1/6/25 at 2:15 p.m., the Director of Nursing Services confirmed to surveyors that the above information was accurate.

This deficiency centers on the absence of a required baseline care plan for a newly admitted resident with a documented pressure-related skin issue, as confirmed through record review and interview with facility leadership.