Based on record review, observation, resident and staff interviews, wound nurse practi-tioner interview, review of wound notes, hospital records, wound clinic records, review of the information from the National Pressure Injury Advisory Panel (NPIAP), and policy re-view, the facility failed to ensure the physician ordered treatments were completed as di-rected and failed to ensure interventions were implemented to prevent the development of, worsening of and promote the healing of avoidable facility acquired stage IV and un-stageable pressure ulcers with the development of osteomyelitis (a serious infection and inflammation of the bone or bone marrow, typically caused by bacteria (most commonly Staphylococcus aureus) or fungi. …
F686 citations in Ohio
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
Ohio cites F686 more often than its own record predicts
1.52 times the share F686 takes of citations nationally.
Of every deficiency written in Ohio 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 Ohio surveyors wrote
F686 findings written in Ohio, 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, facility policy review and interview, the facility failed to develop and implement a comprehensive and effective pressure ulcer prevention program to prevent pressure ulcers from developing and/or worsening. The facility failed to ensure proper and appropriate wound care treatments were provided, failed to ensure pressure ulcer prevention measures were obtained and implemented timely, and failed to ensure ongoing monitoring/weekly skin checks were completed to prevent the worsening of pressure ulcers and/or the development of new pressure ulcers.Actual harm occurred on 08/11/26 when Resident #70, who was at risk for pressure ulcer development and required substantial staff assistance for activities of daily living, was assessed to have a new in-house deep tissue… …
Based on resident record review, interview, and facility policy review, the facility failed to implement physician orders and interventions for Resident #2's stage four pressure ulcer. Additionally, the facility failed to comprehensively assess a new pressure ulcer for Resident #29. This affected two residents (#2 and #29) of three residents sampled for pressure ulcers. The facility census was 68.Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 04/30/25. …
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 3.32% | 1.62× |
| 2024 | 2.98% | 1.43× |
| 2025 | 3.00% | 1.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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