Based on record review, review of facility policy, and staff interviews, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 1 closed record (Resident #65) with pressure ulcers. Failure to ensure adequate monitoring and assessment by a provider resulted in the worsening of a facility acquired pressure ulcer. Findings Include: Review of the facility policy titled Pressure Injury Prevention and Management occurred on 07/29/26. The policy, dated 02/23/18 stated, . …
F686 citations in North Dakota
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 Dakota cites F686 less often than its own record predicts
0.98 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Dakota 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 Dakota surveyors wrote
F686 findings written in North Dakota, 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, record review, review of facility policy, and staff interviews, the facility failed to provide care and services to prevent the development of pressure ulcers for 2 of 6 sampled residents (Residents #1 and #6) with pressure ulcers. Failure to provide repositioning and utilize pressure relief devices appropriately may result in the development/worsening of pressure ulcers. Findings include: Review of the facility policy titled Pressure Ulcers occurred on 06/16/26. This policy, dated March 2026, stated, . will use prevention and assessment interventions to ensure that a resident entering the location without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. …
The short window
Recent years
| Year | Share of North Dakota citations | vs expected |
|---|---|---|
| 2023 | 2.81% | 1.37× |
| 2024 | 1.98% | 0.95× |
| 2025 | 1.93% | 0.98× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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