Based on review of facility policy, clinical records, observation, and interviews with staff and family, it was determined that the facility failed to provide preventative interventions, and treatments which resulted in the development of avoidable pressure ulcers for two of two residents (Resident R5 and Resident R13), resulting in an infection for one of two residents (Resident R5). This failure resulted in an immediate jeopardy. Findings Include: Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, muscle wasting and atrophy (occurs when muscle fibers shrink due to disuse, aging, malnutrition, genetic factors, or nerve-related conditions), and Parkinson's Disease (a disorder of the… …
F686 citations in Pennsylvania
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
Pennsylvania cites F686 less often than its own record predicts
0.97 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F686 findings written in Pennsylvania, 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 clinical record review, facility policy review, observation, and staff interviews, it was determined that the facility failed to consistently implement interventions to prevent the development and worsening of pressure injuries for one of 12 residents reviewed (Resident 2). This failure resulted in actual harm when Resident 2 developed a Stage 2 pressure injury that subsequently deteriorated and was identified as an unstageable pressure injury.Findings include: According to the National Pressure Injury Advisory Panel (NPUAP) September 2025 a pressure injury is localized damage to the skin and underlying soft tissue. The skin injury occurs due to intense and/ or prolonged pressure or pressure in combination with shear. …
Based on select facility policy, observations, clinical record review, and staff interviews, it was determined that the facility failed to consistently implement preventive interventions to avoid the development of pressure injuries for one of 31 residents reviewed (Resident 8). Findings include: A review of the facility policy titled Pressure Ulcers/Skin Breakdown Clinical Protocol, last reviewed by the facility on January 29, 2026, revealed it is the facility policy to assess and document an individual's significant risk factors for developing pressure ulcers. The interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 2.28% | 1.11× |
| 2024 | 2.02% | 0.97× |
| 2025 | 1.91% | 0.97× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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