Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to developed interventions in Resident R108's baseline care plan, who was identified at high risk for falls. This failure resulted in actual harm to Resident 108 who sustained a fall and a left [CONDITION(S)]. The facility failed to develop baseline care plans within 48 hours of admission related to falls, [CONDITION(S)] medications, transmission based precautions, diabetes and cardiac conditions for six of 37 residents reviewed (Residents R108, R97, R270, R271, R273 and R83). Findings include: Review of facility policy, Baseline Care Plan - Guidelines undated, revealed that, Baseline Care Plan must be completed within 48 hours of admission to the facility. …
F655 citations in Pennsylvania
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.
Against expectation — 2025
Pennsylvania cites F655 more often than its own record predicts
1.48 times the share F655 takes of citations nationally.
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Pennsylvania surveyors wrote
F655 findings written in Pennsylvania, 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.
Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan for a resident within 48 hours of a resident's admission for one of six residents reviewed (Resident R27).Findings include: Review of the facility policy Care Plan-Baseline last reviewed 7/15/26, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care. …
Based on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for seven of nine residents reviewed for baseline care plans (Residents R39, R59, R68, R183. R188, R22 and R65). Findings include: Resident R39's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease that results in difficulty breathing, cough, and mucus production) diabetes, and Hodgkin lymphoma (cancer of the lymph nodes). R39's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R39 and/or his/her representative. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.92% | 1.15× |
| 2024 | 1.03% | 1.49× |
| 2025 | 0.97% | 1.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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