of F691 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202582
Every F691 citation surveyors wrote nationally that year.
Facilities cited81
Distinct nursing homes with at least one F691 finding.
The harm level
How severely F691 is cited
3.9% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K10.3%
L—
Actual harm
G113.3%
H10.3%
I—
No harm, potential for more than minimal
D29186.9%
E298.7%
F10.3%
No harm, potential for minimal
A—
B—
C10.3%
Every recorded F691 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F691 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternApril 13, 2025
Based on observations, interviews, and record review, the facility failed to ensure that residents who required colostomy, urostomy, or ileostomy services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 residents (Resident #1) reviewed for ostomy care in that:
1.
The facility failed to ensure Resident #1's ileostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, to divert waste from the small intestine), wafer (the piece of the pouching system that sticks to your body and holds your pouch in place and should help protect the skin around your stoma from damage) and bag were in place.
2. …
Based on interview and record review, the facility failed to follow the resident's plan of care and accepted standards of practice for ostomy care by failing to monitor, measure, and document ileostomy output, resulting in lack of adequate nurse-to-provider communication, for one of one resident (R1) reviewed for ostomy care and services. This failure resulted in R1 having significant abdominal pain, being transported to the hospital, and diagnosed with a bowel obstruction.Findings include: R1's facility sheet shows diagnoses of colostomy status. …
D · No harm, potential for more than minimal, isolatedAugust 27, 2026
Based on interview and record review, the facility failed to ensure urostomy appliance changes were completed for 1 of 3 residents (R1) reviewed for quality of care in a sample of 4.The findings include:R1's Resident Face Sheet documented R1 was admitted to the facility on [DATE] at 5:30 PM, with a primary diagnosis of Spastic Quadriplegic Cerebral Palsy and other diagnoses including: Neuromuscular dysfunction of bladder and Extended Spectrum Beta Lactamase (ESBL) resistance-urine.R1's Care Plan with a revision date of 8/6/26 documents a problem area of Resident requires a urostomy, risk for infection hx (history) of recurrent urinary infections, neurogenic dysfunction. …
C · No harm, potential for minimal, widespreadSeptember 25, 2024
Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 1:50 PM, it was determined that the facility failed to ensure have a policy and procedure so that residents receive care consistent with the standard of professional practice, necessary care and treatment including medical and nursing care and services when they need a urostomy.
Findings include:
1. During the review of the procedure's manual, the policy and procedure with professional standards of Urostomy practice. The Compliance Officer (employee #2) was interviewed to see if they could find it in the manual. …
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