Based on surveyor observation(s), review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed to implement preventive measures to prevent a pressure injury for residents identified at low (mild) or moderate risk for impaired skin integrity. These failures resulted in 3 of 3 residents with facility acquired pressure injuries that were reviewed during the survey (#105, #221 and #11). On 10-21-19 at 4:15 PM, an immediate jeopardy (IJ) for residents at low (mild) to moderate risk for pressure injury was determined. …
F686 citations in Maryland
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
Maryland cites F686 less often than its own record predicts
0.80 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland 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 Maryland surveyors wrote
F686 findings written in Maryland, 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 complaint, reviews of all pertinent documents and a closed medical record, and interviews with facility staff, it was determined that the facility failed to implement preventative measures to prevent the development and deterioration of a resident's pressure ulcers. This was evident for 1 (Resident #2) out of 4 residents reviewed during a survey. The findings include: On 03/30/26 the Office of Health Care Quality received a complaint with concerns that Resident #2 was not provided with quality of care. …
Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers . This is evident for 1 (Resident #7) of 3 residents reviewed for pressure ulcers during a complaint survey.The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or… …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 1.61% | 0.79× |
| 2024 | 1.54% | 0.74× |
| 2025 | 1.58% | 0.80× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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