of F686 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20252,131
Every F686 citation surveyors wrote nationally that year.
Facilities cited1,915
Distinct nursing homes with at least one F686 finding.
The harm level
How severely F686 is cited
22.5% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J1691.9%
K991.1%
L—
Actual harm
G1,69019.1%
H360.4%
I—
No harm, potential for more than minimal
D6,04168.2%
E8089.1%
F20.0%
No harm, potential for minimal
A—
B100.1%
C—
Every recorded F686 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F686 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.
J · Immediate jeopardy, isolatedAugust 25, 2026
Based on record review and interview, the facility failed to ensure a resident at risk for pressure ulcers was assessed and monitored to prevent pressure ulcers for 1 (#3) of 2 sampled residents reviewed for pressure ulcers.Resident #3 was admitted to the facility on [DATE] with a skin condition described as MASD with early pressure areas to the upper buttocks. On 07/13/26, Resident #3 was assessed and the wound located in the sacral area had declined to a stage 2 pressure ulcer. A note from the DON showed the wound should have been staged as a stage 3 pressure ulcer at that time. Weekly skin checks for Resident #3 showed an increase in the dimensions and an overall decline of the wound status. …
Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (26) who developed a pressure ulcer to his left heel after he admitted to the facility on [DATE].Findings include: 1. Observation and Interview on 9/1/26 at 1:43 p.m. with resident 26 in his room revealed he had a boot on his left foot, and he stated he had his left foot amputated. 2. Observation and Interview on 9/2/26 at 3:30 p.m. with resident 26 in his room revealed he had a wound on the bottom of his left heel. The wound was black in color, and the skin was not open. Resident 26 denied pain in that area unless the area was pushed on. …
D · No harm, potential for more than minimal, isolatedSeptember 17, 2026
Based on observation, interview and record review, the facility failed to ensure residents with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents (Resident #5) reviewed for pressure ulcers. The facility failed to ensure LVN A followed physician orders for Resident #5's wound care to his left heel. This failure could place residents at risk of delayed wound healing, worsening wounds resulting in undue pain and discomfort, and deterioration on residents' general condition.Findings include: Record review of the admission record for Resident #5, dated 09/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (a… …
B · No harm, potential for minimal, patternFebruary 18, 2026
Based on observation, interview, and medical record review, the facility failed to ensure one of 27 final sampled residents (Resident 1) received services to prevent pressure ulcers. * Resident 1's LAL mattress settings were not set according to Resident 1's weight. This failure posed the risk of Resident 1's pressure ulcers not receiving full treatment to prevent further decline.Findings: On 2/11/26 at 1239 hours, Resident 1 was observed in bed on a LAL mattress. The mattress settings showed the weight setting was set to 15 pounds. Resident 1 appeared to weigh more than 15 pounds. Medical record review for Resident 1 was initiated on 2/11/26. Resident 1 was readmitted to the facility on [DATE]. …
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Provide routine and 24-hour emergency dental care for each resident.
Cited in the same inspection, not caused by one another.
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