Based on interview and record review, the facility failed to ensure residents with pressure ulcers (injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) received assessment, care, and treatment in accordance with their policy for one resident (Resident #1) who developed a new pressure ulcer at the facility. On 04/05/26, staff identified an open area to the resident's gluteal fold. Staff failed to document physician orders for barrier cream on the resident's treatment administration record (TAR) and failed to administer the treatment. Staff failed to complete skin assessments on a weekly basis, as ordered by the physician. …
F686 citations in Missouri
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
Missouri cites F686 less often than its own record predicts
0.73 times the national share — cited less often here than elsewhere.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F686 findings written in Missouri, 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 ensure one resident (Resident #1) of nine sampled residents received the necessary care and services including appropriate individualized interventions to prevent the development of three unstageable pressure ulcers that were covered with eschar and required surgical removal of the eschar while the resident was in the hospital for infection in the sacral wound. The facility census was 79.Review of the undated facility policy for Pressure Injury Prevention and Management showed:-This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure… …
Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to document accurate wound assessments, obtain and update orders timely, follow physician orders, provide treatment as ordered, and care plan for one resident (Resident # 1) with a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 71. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 1.56% | 0.76× |
| 2024 | 1.61% | 0.77× |
| 2025 | 1.43% | 0.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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