Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 (Resident's #17, #22) of 6 residents reviewed for baseline care plans. The facility failed to ensure Resident #17's and Resident #22's baseline care plans addressed their mobility abilities.The facility failed to complete Resident #27 and Resident #44's baseline care plans.This failure could place residents at risk of getting insufficient care, not having personal needs not met resulting in hospitalizations and injuries related to falls. An IJ was identified on 09/04/25. …
F655 · Baseline care plan
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F655 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F655 finding.
The harm level
How severely F655 is cited
1.1% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J170.5% | K— | L— |
| Actual harm | G170.5% | H10.0% | I— |
| No harm, potential for more than minimal | D2,61081.7% | E46214.5% | F250.8% |
| No harm, potential for minimal | A— | B531.7% | C90.3% |
In the surveyor’s words
What an F655 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 observation, interview, and record review, the facility failed to develop a base-line person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (CR #1) reviewed for base-line care plans. The facility failed to provide CR #1 with a base-line personal-centered care that addressed, monitored, and managed the development of wounds to CR #1's posterior area. This failure places residents at risk for appropriate care, treatment, monitoring, and timely assessment for the development of infections, resulting in hospitalization, a decline in health, or death. …
Based on record review and interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents for one (Resident #63) of six residents reviewed for baseline care plans for newly admitted residents in that: The facility did not initiate a baseline careplan for Resident #63 for six days after she was admitted on [DATE]. This failure could place residents at risk of not having their needs met and increases the risk for residents to experience adverse events, exacerbations or complications from medical conditions.The findings include:Record review of Resident #63's face sheet, dated 09/01/2026, revealed an [AGE] year-old female with an admission date of 07/03/2026. …
Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan was initiated upon admission for one of 34 final sampled residents (Resident 225). * The facility failed to ensure the baseline care plan was initiated for Resident 225 use of the oxygen. This failure put Resident 225 at risk of not receiving resident-centered care.Findings: Review of the facility's P&P titled Baseline Care Plan with revised date 1/2026 showed completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure… …
By state — 2025
Where F655 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Maryland1.61× · 32 citations
- Massachusetts1.53× · 26 citations
- Pennsylvania1.48× · 64 citations
- Texas1.38× · 87 citations
- Ohio0.88× · 37 citations
- California0.76× · 79 citations
Co-occurrence
Cited alongside F655
Of the 2025 surveys that cited F655, these tags appeared in the same inspection more often than chance would predict.
- F6365.9% of F655 surveys · 5.7× chance
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- F6374.9% of F655 surveys · 5.0× chance
Assess the resident when there is a significant change in condition
- F6255.3% of F655 surveys · 4.5× chance
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- F7306.3% of F655 surveys · 4.4× chance
Observe each nurse aide's job performance and give regular training.
- F75810.5% of F655 surveys · 4.0× chance
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Cited in the same inspection, not caused by one another.
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