Based on observation, interview, and record review, the facility failed to ensure that appropriate colostomy care was provided in accordance with professional standards of practice, physician orders, and individual care needs. This was evidence of 1 (Resident #86) of 1 resident reviewed for colostomy care during this annual survey.The findings include:On 08/03/2026 at 11:25 AM, during an initial resident interview, Resident #86 expressed concern regarding his/her colostomy care. Resident #86 stated that nursing staff frequently utilized incorrect ostomy supplies, causing the pouching system to lose adhesion and pop off due to waste overload. …
F691 citations in Maryland
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
Maryland cites F691 more often than its own record predicts
1.74 times the share F691 takes of citations nationally.
Of every deficiency written in Maryland 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 Maryland surveyors wrote
F691 findings written in Maryland, 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 Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 2.09× |
| 2024 | 0.27% | 3.33× |
| 2025 | 0.13% | 1.74× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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