Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with standards of practice, to prevent pressure ulcers, does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and a resident with a pressure ulcer receives necessary treatment and services to promote healing and prevent infection for 3 of 5 sampled residents reviewed for pressure ulcers (ID #s 1,7, & 8). …
F686 citations in Rhode Island
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
Rhode Island cites F686 more often than its own record predicts
1.68 times the share F686 takes of citations nationally.
Of every deficiency written in Rhode Island 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 Rhode Island surveyors wrote
F686 findings written in Rhode Island, 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 and staff interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers (an injury to the skin and underlying tissue caused by prolonged pressure on the skin over a bony prominence), Resident ID #2. Specifically, the resident was admitted to the facility without any skin impairments and while at the facility s/he developed a stage III pressure ulcer (an ulcer that has completely broken through the top 2 layers of skin and into the fat layer below) and an unstageable pressure ulcer (an ulcer that occurs when the wound bed is completely covered by dead tissue, slough, or eschar,… …
Based on clinical record review and staff interview, the facility failed to ensure that residents with pressure ulcers (tissue damage or wounds caused by prolonged pressure to an area of the body) receive the necessary treatment and services, consistent with professional standards of practice, for 2 of 2 residents reviewed with sacral (the area just above the buttocks and at the base of the spine) pressure ulcers, Resident ID #s 39 and 3.Findings are as follows:1. Record review revealed Resident ID #39 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, dementia and pain.Review of a care plan dated 1/26/2026 revealed the resident is at risk for skin alterations related to incontinence, cognitive impairment, and limited mobility, and the resident… …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 4.56% | 2.22× |
| 2024 | 3.25% | 1.56× |
| 2025 | 3.29% | 1.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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