Based on observations, interviews, and record review, the facility failed to provide care and treatment to prevent the development and worsening of pressure injury's (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the coccyx, hips, heels, or elbows) for six Residents (#264, #103, #97, #60, #63 and #20) out of a total sample of 30 residents. Specifically: 1. For Resident #264, the facility failed to provide care and treatment to prevent the development of pressure ulcers. Specifically, the facility failed to provide care and treatment resulting in a worsening stage 4 pressure injury to the coccyx with a major wound infection requiring antibiotics treatment, surgical debridement, hospitalization and ultimate death. 2. …
F686 citations in Massachusetts
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
Massachusetts cites F686 more often than its own record predicts
1.14 times the share F686 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F686 findings written in Massachusetts, 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, interviews, and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing a.) ensure treatment orders were transcribed and implemented per the Wound Nurse Practitioner's recommendations and b.) accurately implement a wound intervention of an air mattress for four Residents (#152, #32 , #4, and #5) out of a total sample of 33 residents. 1.For Resident #152, the facility failed to prevent an existing ankle wound that was present on admission to the facility from worsening from a Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed) pressure ulcer to a Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle) pressure ulcer by not… …
Based on observations, interviews, and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing for two Residents (#5 and #203), out of a total sample of 35 residents. Specifically, the facility failed to:1. Evaluate and implement new interventions, if indicated, for Resident #5's right mid-back pressure injury for 21 days after observation of a change in the wound's condition; and2. For Resident #203, ensure the Wound Consultant's recommendation for offloading felt to his/her left plantar heel pressure injury was implemented. Findings include: 1. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 2.23% | 1.09× |
| 2024 | 2.07% | 0.99× |
| 2025 | 2.24% | 1.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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