Based on observation, record review and interviews, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#130) of three residents reviewed for colostomy care out of 53 sample residents. Resident #130 was admitted to the facility on [DATE] with diagnoses of cognitive-communication deficit, anxiety disorder and with toxic megacolon (swelling and inflammation of the colon) that required a colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). …
F691 citations in Colorado
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 — 2024
Colorado cites F691 more often than its own record predicts
1.88 times the share F691 takes of citations nationally.
Of every deficiency written in Colorado in 2024, 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 Colorado surveyors wrote
F691 findings written in Colorado, 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 observations, interviews and record review, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. for two (#15 and #11) of two residents reviewed for colostomy care out of 29 sample residents. Specifically, the facility failed to ensure Resident #15's and Resident #11's colostomy bags were maintained per physician's guidance and professional standards of practice. Findings include: I. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 3.13× |
| 2024 | 0.15% | 1.88× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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