Based on interview and record review, the facility failed to prevent the development of pressure injuries and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) by failing to: 1. Implement interventions to prevent PI (Pressure Injury - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for Resident 1 who was admitted without PI, by not repositioning according to the Care Plan (CP- a document that details an individual's health conditions, treatments, needs, and goals, serving as a blueprint for their healthcare and support services) for quadriplegia dated 6/27/25. No documentation repositioning was done. Resident bedbound.2. …
F686 citations in California
Pressure ulcers · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F686 less often than its own record predicts
0.88 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F686.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F686 findings written in California, 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 interview and record review, the facility failed to prevent the development and worsening of a pressure ulcer (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence) for six of eight residents (Residents 1, 2, 5, 6, 7, and 8) who have a facility acquired PU when:1. For Resident 1, interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) did not accurately identify and assess the presence of a PU on the left buttock to provide necessary pressure ulcer treatments and nursing interventions to aid wound healing. …
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the care and services were provided to prevent the development of a pressure ulcer for one of seven sampled residents (Resident 1). * The facility failed to ensure Resident 1's skin inspection was performed daily and as needed during ADL care. The failure had the potential to negatively impact on the health outcome and delay treatments of the resident.Findings: Review of facility's P&P titled Prevention of Pressure Injuries dated revised 4/2020 showed to inspect the skin on a daily basis when performing or assisting with personal care or ADLs.a. identify any signs of developing pressure injuries (ie. non-blanchable erythema). …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.62% | 0.79× |
| 2024 | 1.97% | 0.95× |
| 2025 | 1.73% | 0.88× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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