Based on observations, record review and staff interviews, and review of facility policy titled Documentation of Skin and Wound Care, the facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown in order to identify breakdown timely for six residents (R) (R1, R3, R8, R9, R11 and R12) and failed to perform treatments as ordered by the physician and/or recommended by the Wound Care Nurse Practitioner for three residents (R3, R11 and R12) of seven residents reviewed for pressure ulcers. The total sample size was 27. …
F686 citations in Georgia
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
Georgia cites F686 less often than its own record predicts
0.38 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia 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 Georgia surveyors wrote
F686 findings written in Georgia, 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, record review, staff interviews, and policy review, the facility failed to implement pressure ulcer prevention measures and timely treatment and interventions for one of four residents (Resident (R) 28) reviewed for pressure ulcers. This failure contributed to the development and subsequent decline of a potentially avoidable stage III pressure ulcer on R28's sacrum. Actual harm was identified to have occurred on 04/20/2026 when R28 was noted to have developed a Stage III pressure ulcer to the sacrum after interventions to prevent pressure ulcers were not implemented in a timely manner. …
Based on observations, record review, staff interviews, and review of facility policy titled, Assessment and Treatment of Pressure Ulcers/Injuries, the facility failed to identify a change in wound condition for one resident (R) (R10) of three residents with pressure ulcers. The facility's failure placed the resident at risk for wound deterioration and delayed necessary modifications to the treatment plan.Findings include:Review of the facility policy titled, Assessment and Treatment of Pressure Ulcers/Injuries, dated 12/27/2025 revealed it is the intent of the facility to provide a comprehensive assessment of the resident's clinical condition to identify potential risk for pressure ulcer/injuries (PU/PI) development and implement a plan of care to prevent pressure ulcer/injury development… …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 1.19% | 0.58× |
| 2024 | 1.07% | 0.52× |
| 2025 | 0.74% | 0.38× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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