Based on resident representative and staff interview, and medical record review, the facility failed to provide services to prevent, treat, and heal pressure ulcers for 1 of 4 sampled residents (#98) reviewed for pressure ulcers. This failure resulted in actual harm to resident #98 who developed pressure ulcers. The findings were: 1. Review of the admission MDS assessment, dated 5/18/25, showed resident (#98) had a BIMS score of 3 out of 15, which indicated s/he had severe cognitive impairment, and diagnoses which include type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and heart failure. Further review showed no wounds were present upon admission and the resident was at risk for pressure ulcers / injuries. The following concerns were identified: a. …
F686 citations in Wyoming
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
Wyoming cites F686 more often than its own record predicts
1.14 times the share F686 takes of citations nationally.
Of every deficiency written in Wyoming 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 Wyoming surveyors wrote
F686 findings written in Wyoming, 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, staff interview, record review, and policy and procedure review, the facility failed to ensure thorough wound assessments were completed for 1 of 4 sample residents (#8) reviewed for wound care. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #8 admitted to the facility on [DATE] and had a BIMS score of 99, which indicated the resident had severe cognitive deficits. The resident had diagnoses which included non-traumatic brain dysfunction, non-Alzheimer's dementia, and anxiety disorder. Further review showed the resident was at risk for developing pressure ulcers/injuries, and had 2 unstageable pressure injuries presenting as deep tissue injuries. The following concerns were identified:a. …
The short window
Recent years
| Year | Share of Wyoming citations | vs expected |
|---|---|---|
| 2023 | 0.67% | 0.33× |
| 2024 | 0.89% | 0.43× |
| 2025 | 2.23% | 1.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wyoming surveyors cite →
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