Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to provide ileostomy care in accordance with professional standards of practice for one of two sampled residents (#146). This deficient practice could lead to ileostomy skin complications. Findings include: Resident #146 was admitted to the facility on [DATE] with diagnoses that included peritoneal abscess, Type 2 diabetes mellitus, depression, colostomy and encounter for surgical aftercare following surgery on the digestive system. A skilled nursing note dated March 21, 2025, revealed the resident had an ileostomy, rather than a colostomy. …
F691 citations in Arizona
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Arizona cites F691 more often than its own record predicts
1.69 times the share F691 takes of citations nationally.
Of every deficiency written in Arizona in 2025, this is the portion that was F691.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arizona surveyors wrote
F691 findings written in Arizona, 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.
The short window
Recent years
| Year | Share of Arizona citations | vs expected |
|---|---|---|
| 2023 | 0.35% | 4.27× |
| 2025 | 0.13% | 1.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arizona surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction