Based on observation, staff interview, record review, and policy review, it was determined the facility failed to prevent the development or worsening of pressure ulcers in the facility. This was true for 4 of 10 residents (#13, #36, #131, and #134) reviewed for pressure ulcers. Resident #131's health and safety was placed in Immediate Jeopardy when his sacral pressure ulcer worsened and required surgical intervention. Resident #13 was harmed when she developed a pressure ulcer to her left antecubital (crease of elbow) and a Stage II pressure ulcer to her left heel. Resident #36 was harmed when she developed an unstageable pressure ulcer to her to left heel. …
F686 citations in Idaho
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
Idaho cites F686 less often than its own record predicts
0.17 times the national share — cited less often here than elsewhere.
Of every deficiency written in Idaho 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 Idaho surveyors wrote
F686 findings written in Idaho, 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, review of records and interviews, it was determined the facility failed to ensure residents consistently received necessary care to prevent pressure ulcers and infection from developing. This was true for 1 of 1 resident (Resident #9) reviewed for pressure ulcer. This deficient practice caused harm to Resident #9 when he developed pressure wound and infection to his right palm which required use of antibiotics. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including right-hand contracture and aphasia (an impairment of language due to brain injury, affecting the production or comprehension of speech and the ability to read or write) following a stroke. …
Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure necessary pressure relieving boots were consistently applied as ordered to prevent development of pressure injuries and promote skin integrity. This was true for 1 of 5 residents (Resident #1) reviewed for pressure-injury prevention. This failure placed Resident #1 at increased risk for harm related to pressure-related skin breakdown. Findings includeThe facility's Skin and Wound Monitoring and Management Policy, revised 4/2025 documented:1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. …
The short window
Recent years
| Year | Share of Idaho citations | vs expected |
|---|---|---|
| 2023 | 0.48% | 0.23× |
| 2024 | 0.21% | 0.10× |
| 2025 | 0.33% | 0.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Idaho surveyors cite →
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