Based on observation, interview, and document review the facility failed to identify, comprehensively assess, monitor, and develop interventions to prevent/mitigate the risk of pressure ulcer development and/or deterioration for 4 of 4 residents (R1, R2, R3, R5). The facility's failure resulted in Immediate Jeopardy (IJ) for R1 when the facility failed to prevent and manage impaired skin integrity that progressed to bone and soft tissue infections which required hospitalization for treatment and management.The IJ began on 12/31/25 after R1's existing buttock wound(s) were documented as black and blue tissue to the buttocks, with ongoing inconsistent identification of skin integrity and without completion of comprehensive wound assessments, physician notification, or implementation of… …
F686 citations in Minnesota
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
Minnesota cites F686 more often than its own record predicts
1.19 times the share F686 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F686 findings written in Minnesota, 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 document review, the facility failed to comprehensively assess, monitor, evaluate, and implement individualized interventions to prevent/treat pressure ulcers, including timely physician notification for 1 of 3 residents (R1) reviewed for pressure ulcers. The facility's failures resulted in harm when R1's moisture associated skin damage deteriorated to a stage 3 pressure ulcer.Findings include:Findings include:Moisture-Associated Skin Damage (MASD): Inflammation and erosion of the skin caused by prolonged or continuous exposure to moisture and chemical irritants, including urine, feces, sweat, or wound drainage. …
Based on record review and interview, the facility failed to ensure necessary wound care treatments were initiated, carried out, and documented as ordered for 1 of 1 resident (R108) who presented with skin impairment of a scab on the coccyx (commonly referred as the tailbone) upon admission.Findings include:R108's admission Minimum Data Set (MDS) dated [DATE], identified R108 was cognitively intact. Diagnosis included end stage renal (kidney) disease and cirrhosis (scaring) of the liver. Review of R108's Electronic Medical Record (EMR) and Treatment Administration Record (TAR) confirmed wound care treatments were completed only on 4/15/2026 with no further documented treatments or ongoing care provided thereafter during the stay at the facility. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 2.45% | 1.19× |
| 2024 | 3.11% | 1.49× |
| 2025 | 2.33% | 1.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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