F686 — Pressure Ulcers / Treatment
Failure to ensure residents receive care consistent with professional standards to prevent the development of pressure injuries and to provide treatment that promotes healing of existing wounds.
Reg cite · 42 CFR 483.25(b)(1)
148 surveys in corpus
27 states
What surveyors look for
- Braden scale completed on admission, weekly, and after any condition change
- Pressure-relief schedule documented for residents scored ≤18, with q2h turning evidenced in the TAR
- Wound measurements (length × width × depth) weekly with photo documentation
- Nutritional consults for residents with Stage 2+ wounds; protein supplementation orders
Common gotchas
- Turning schedules charted but residents observed in the same position across multiple rounds
- Wound measurements not progressing as expected without documented physician reassessment
- Hospital-acquired pressure injuries documented as 'present on admission' without supporting evidence
- Heel offloading boots not on residents at risk per care plan
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, record review and review of a facility policy titled, Pressure Injury, the facility failed to ensure
treatments were provided to Resident Identifier (RI) #265's Stage I sacrum pressure ulcer as ordered by
the physician.
This deficient practice affected RI #265, one of five sampled residents reviewed for pressure ulcers.
Findings include:
RI #…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On [date] at 11:38 AM, the surveyor conducted an interview with the LPN/SDC (Staff Development
Coordinator). The SDC said back in February of 2023, she believed she was helping to provide care to
pressure ulcers. The SDC said according to RI #265's admission wound assessment note, RI #256 was
admitted to the facility with a Stage 1 sacral pressure ulcer. The SDC said the type treatment implemented
on admission was to cleanse with NS wash, apply skin prep, and a Silicone dressings every MWF. The
SDC said the evid…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to provide services that promote the prevention
of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence)
injury for one of three sampled residents (Resident) as evidenced by failing to monitor the functionality
of the resident's low air loss matt…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the monitoring of Resident`s LALM in his TAR or MAR. LVN 5 stated Resident`s physician order for
LALM was not placed on the administrative section of the order. Therefore, the order was not transferred to
Resident`s TAR or MAR as a task to be completed. She (LVN 5) stated this order was missed and it was
never carried out. LVN 5 further stated she is unable to say for how long Resident`s LALM panel was off,
or whether or not his LALM was functioning at the time of observation. LVN 5 stated the LALM company
repre…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Based on observation, interview, and record review, the facility failed to provide care consistent with
professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin
that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) for one
of one sampled resident (Resident) reviewed for pressure ulcers by failing to set the low air loss mattress
(LA…
Accepted POC examples
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