Based on record review and interviews with staff, Wound Nurse Practitioner (NP) #1, Physician Assistant, Facility Nurse Practitioner, Physician, and Family Member, the facility failed to provide treatment and services, consistent with the facility's wound protocol, to promote healing and identify infection of the pressure areas Resident #1 had on admission. Resident #1's Stage 2 pressure ulcers deteriorated, increased in size and developed odor, drainage, and eschar (dead tissue) during her one month stay. Staff did not consult with medical staff when there was drainage and deterioration of the wound. On the day of discharge, the Family Member took Resident #1 directly to the hospital where she was diagnosed with a stage 4, open and infected decubitus ulcer of the sacrum. …
F686 citations in North Carolina
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
North Carolina cites F686 less often than its own record predicts
0.59 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F686 findings written in North Carolina, 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 record review, observations, staff and provider interviews, the facility failed to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer. The facility failed to recognize the pressure ulcer was not improving and involve a wound provider. On admission, 4/20/26, the wound measurements were 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth. When the wound provider assessed the pressure ulcer on 5/21/26 the wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth.Findings Included: Review of the hospital Discharge summary dated [DATE] revealed Resident #17 was discharged to the facility with multiple wound care needs, including a former enterocutaneous fistula site (an abnormal opening connecting the intestine to… …
Based on record review and interviews with the Nurse Practitioner and staff, the facility failed to accurately transcribe and carry out physician orders for protective skin care for 1 of 3 residents reviewed with pressure ulcers (Resident #48).The findings included: Resident #48 was originally admitted to the facility on [DATE]. Her diagnoses included contractures of both knees and protein calorie malnutrition. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #48 had severely impaired cognition and limited range of motion to both lower extremities. She was coded with one unstageable pressure ulcer. A review of Resident #48's care plan, last reviewed 6/23/25, included a focus area for impaired mobility, thin/fragile skin, poor oral intake. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 1.15% | 0.56× |
| 2024 | 1.03% | 0.50× |
| 2025 | 1.16% | 0.59× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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