Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure injuries; failed to provide wound care services consistent with professional standards of practice; and failed to identify and treat signs and symptoms of wound infection for 2 of 6 residents reviewed for acquired pressure injuries, out of a total sample of 10 residents, (#2 and #4). These failures contributed to resident #2's pressure injuries, a severe infection, and his subsequent death. Resident #2 suffered a life threatening illness, pain, discomfort, permanent disfigurement, and impairment as his wounds worsened until his death. On [DATE], ten days after admission to the facility, a nurse identified pressure injuries on resident #2's heels. …
F686 citations in Florida
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
Florida cites F686 less often than its own record predicts
0.58 times the national share — cited less often here than elsewhere.
Of every deficiency written in Florida 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 Florida surveyors wrote
F686 findings written in Florida, 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 record review, facility policy review and staff interviews, the facility failed to monitor skin integrity and treat skin ulceration related to the use of a splinting device for 1 (Resident #1) of 3 residents reviewed, resulting in the development and worsening of an avoidable pressure ulcer.The findings included:Review of the facility provided Wound Prevention Treatment and Overview Policy and Procedure with an effective date of August 2026 revealed, The facility strives to ensure that a resident entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. …
Based on interview and record review, the facility failed to provide consistent wound care, failed to ensure daily treatment was completed as ordered, and failed to monitor and document the progression of an in house acquired pressure ulcer, which resulted in the worsening of pressure wounds for one resident (#2) out of three residents reviewed for pressure ulcers.Findings Included: On 8/11/26 at 1:42 p.m., interviews were conducted with the Wound Care Supervisor (WCS) and the Nursing Home Administrator (NHA). The WCS stated wound rounds are performed on Mondays, Wednesdays, and Fridays. The WCS further stated residents who attend dialysis on Wednesdays may miss wound treatment opportunities on that day. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 0.93% | 0.45× |
| 2024 | 1.32% | 0.63× |
| 2025 | 1.14% | 0.58× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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