Based on observation, interview, and record review, the facility failed to ensure two of two residents with a colostomy (a surgical opening in the abdomen that allows waste to pass into a bag) had an adequate supply of colostomy bags (special pouches used to collect waste from the opening) required for proper care. Due to lack of supply, staff washed the colostomy bags. This resulted in residents being required to use rewashed bags, which are not designed for reuse. This deficient practice resulted in R28's reports of humiliation and embarrassment related to odor and the awareness that others might notice it.Findings:On 08/19/25 at 09:35 AM, an interview was conducted with R28, inside her room. …
F691 citations in Guam
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
Guam cites F691 more often than its own record predicts
73.43 times the share F691 takes of citations nationally.
Of every deficiency written in Guam 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 Guam surveyors wrote
F691 findings written in Guam, 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.
What else Guam surveyors cite →
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