Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #212, 213 and 95) reviewed for pressure ulcers, the facility did not provide necessary care and services including skin assessments, RN assessments of wounds, and notification to the physician and dietitian of changes in skin condition. Further, the facility failed to complete treatments according to the physician's orders to prevent the development and worsening of pressure ulcers. Subsequent to these failures, Resident #212 developed a stage III pressure ulcer, multiple unstageable pressure ulcers and Deep Tissue Injures (DTI) which resulted in a finding Immediate Jeopardy. The Findings include: 1. …
F686 citations in Connecticut
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
Connecticut cites F686 more often than its own record predicts
1.24 times the share F686 takes of citations nationally.
Of every deficiency written in Connecticut 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 Connecticut surveyors wrote
F686 findings written in Connecticut, 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 observations, review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews, for nine of twelve sampled residents (Residents #5, #9, #91 #105, #107, #115#122, #142, #151) reviewed for facility acquired pressure injuries, the facility to accurately assess, treat, and implement timely interventions for residents at risk for the development of pressure injuries, resulting in the development of avoidable pressure injuries and the worsening of the pressure injuries resulting in harm. The findings include:Resident #122's diagnoses included cellulitis of left and right lower limbs, generalized muscle weakness, and difficulty walking. …
Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #3) reviewed for positioning and mobility, the facility failed to correctly set an air mattress and offload heels for Resident #3 who had a risk of developing pressure ulcers. The findings include: Resident #3's diagnoses included dementia, metabolic encephalopathy, and history of pressure ulcers. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired and was dependent with bed mobility, toileting, and transfers. …
The short window
Recent years
| Year | Share of Connecticut citations | vs expected |
|---|---|---|
| 2023 | 2.68% | 1.31× |
| 2024 | 2.70% | 1.29× |
| 2025 | 2.43% | 1.24× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Connecticut surveyors cite →
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