Based on interview and record review, the facility failed to identify, assess, and treat a facility-acquired pressure ulcer, prevent a pressure ulcer from worsening, administer wound treatments as ordered, develop and implement pressure relieving interventions and a pressure ulcer care plan for two of three residents (R4, R9) reviewed for pressure ulcers in the sample of 16. This failure resulted in R4 developing a facility acquired pressure ulcer and R4 and R9's wounds worsening without adequate treatment and being transferred to the hospital with lethargy, high fever and requiring extensive hospitalization for diagnoses of sepsis and a stage four decubitus pressure ulcer with osteomyelitis.These failures resulted in an Immediate Jeopardy. …
F686 citations in Illinois
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
Illinois cites F686 more often than its own record predicts
1.91 times the share F686 takes of citations nationally.
Of every deficiency written in Illinois 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 Illinois surveyors wrote
F686 findings written in Illinois, 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, the facility failed to accurately assess, identify, document, implement interventions, and treat pressure wounds/injury for 2 of 3 residents (R1, R2) reviewed for pressure ulcers in a sample of 8. These failures resulted in R1 developing new wounds to the left hip, left ankles, and bilateral elbows and R2 developing a stage 2 pressure ulcer to the coccyx.Findings include:1. R1's admission Record documents an admission date of 11/27/2013 with diagnoses including Hypertensive Heart Disease with heart failure, Crohn's Disease of both small and large intestines without complications, Muscle Wasting and Atrophy, Lack of Coordination, Dysphagia oral phase, Abnormal Posture, Hyperesthesia, Atherosclerotic Heart Disease, Hyperlipidemia, Anxiety,… …
Based on observation, interview and record review facility failed to follow pressure ulcer policy and procedures by not sufficiently off-loading the sacral area at least every two hours, failed to ensure wounds were dressed as prescribed, failed to prevent wound exposure to urine/feces. This affected two of three residents (R4, R5) reviewed for pressure ulcer prevention and treatment. 1. R4 was admitted to the facility 7/17/2023. R4's diagnoses include cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis, toxic encephalopathy, chronic heart failure, acute kidney failure, malnutrition, aphasia, type two diabetes, respiratory failure, chronic kidney disease gastrostomy malfunction, myopathy, dementia, neuromuscular dysfunction of the bladder,… …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 3.96% | 1.93× |
| 2024 | 3.77% | 1.81× |
| 2025 | 3.75% | 1.91× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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