Based on interview and record review, it was determined that for one (R1) out of three (3) residents reviewed for pressure ulcer (PU), the facility failed to ensure that R1 received the necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU's) from developing. R1 had an avoidable unstageable PU develop on bilateral buttocks at the facility causing harm to the resident. Findings include: Cross refer F692 Review of R1's clinical record revealed: 8/25/25 - A progress note from the hospital documented that R1 had a stage II pressure ulcer to the sacrum measuring 4.5 cm L x 0.5 cm W. A wound photograph provided from hospital revealed R1's sacrum open, pink in color, matching the measurements. …
F686 citations in Delaware
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
Delaware cites F686 less often than its own record predicts
0.76 times the national share — cited less often here than elsewhere.
Of every deficiency written in Delaware 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 Delaware surveyors wrote
F686 findings written in Delaware, 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 observation, interview, and record review, it was determined that for one (R4) of two residents reviewed for pressure ulcers, the facility failed to ensure that R4, a resident with a Stage IV pressure injury, received treatment and services consistent with professional standards of practice to promote wound healing and prevent infection during a wound dressing change. Findings include:The facility's Wound Care policy (2001) indicated that staff were required to assemble all necessary supplies before beginning the procedure; maintain a clean field; perform hand hygiene before and after glove removal; use appropriate personal protective equipment (PPE), including gowns and gloves as indicated; utilize a no-touch technique when providing wound care; wear sterile gloves when directly… …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 1.32% | 0.65× |
| 2024 | 1.58% | 0.76× |
| 2025 | 1.49% | 0.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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