Based on interview, observation and record review, the facility failed to assess, notify the family and provider and document the change in the medical record after a resident developed blood in her colostomy (an opening in the abdominal wall, connecting the colon to the outside of the body to divert waste and gas) bag for 1 of 1 residents reviewed for colostomy care. This deficient practice resulted in a delay of treatment for a gastrointestinal bleed (GI) and anemia (low hemoglobin) and unexpected hospitalization. (Resident J) Finding includes: During an interview on 2/9/2026 at 12:02 P.M., Resident J indicated a staff member had found blood and blood clots in her colostomy bag and that the employee had taken a picture of the blood to show the nurse. …
F691 citations in Indiana
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
Indiana cites F691 less often than its own record predicts
0.74 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana 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 Indiana surveyors wrote
F691 findings written in Indiana, 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 record review and interview, the facility failed to provide colostomy care and assess the colostomy and skin surrounding the ostomy, for 1 of 1 resident with a colostomy. (Resident D)Finding includes:Resident D's closed record was reviewed on 7/7/26 at 6:58 a.m. The diagnoses included, but were not limited to, paraplegia related to trauma and colostomy.A Care Plan, dated 6/17/26, indicated an ostomy was present. The interventions included the stoma would be monitored for changes and ostomy care would be provided.An admission Minimum Data Set assessment, dated 6/22/26, indicated a colostomy was present.There was no documentation in the record that indicated colostomy care had been provided, the collection bag had been changed, stoma care had been completed, and the ostomy site had… …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.15% | 1.83× |
| 2024 | 0.16% | 1.95× |
| 2025 | 0.06% | 0.74× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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