Based on clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to implement preventive measures for a resident at risk of developing pressure sores for 4 of 4 residents reviewed for pressure sore prevention and interventions (Resident #73, #83, #85, #94). The facility failed to utilize a pressure reducing wheelchair cushion until after Resident #73 developed an avoidable facility-acquired Stage 4 (full-thickness skin damage) pressure sore to the lower right posterior thigh (which presented with eschar [dead tissue] and treated with antibiotic), failed to maintain pressure relief to the area once developed, and failed to provide major reposition changes and incontinence care over a 7.5 hour period based on a continuous… …
F686 citations in Iowa
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
Iowa cites F686 less often than its own record predicts
0.81 times the national share — cited less often here than elsewhere.
Of every deficiency written in Iowa 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 Iowa surveyors wrote
F686 findings written in Iowa, 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 clinical record review, hospital record review, staff, medical provider and vendor interviews, and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to take steps necessary to avoid the development and worsening of a pressure ulcer for one of four (Resident #8) residents reviewed. This resulted in harm to Resident #8 when her wound continued to worsen and she was sent to the hospital for wound management on [DATE]. Upon admission to the hospital, Resident #8 was diagnosed with a sacral decubitus ulceration extending to the bone. She was additionally diagnosed with an MRSA infection (Methicillin-Resistant Staphylococcus aureus, an antibiotic-resistant infection. …
Based on interviews, record review and policy review, the facility failed to timely identify pressure ulcers, consistently document wounds as pressure ulcers with correct staging, correct measuring, and the facility failed to notify the dietitian when a pressure ulcer was identified, for 1 of 2 residents reviewed (Resident #7). The facility reported a census of 37. Findings include:The Minimum Data Set (MDS) assessment tool identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. …
The short window
Recent years
| Year | Share of Iowa citations | vs expected |
|---|---|---|
| 2023 | 1.88% | 0.92× |
| 2024 | 1.80% | 0.86× |
| 2025 | 1.60% | 0.81× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Iowa surveyors cite →
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