Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had an ileostomy (surgical procedure that creates an opening in the abdominal wall to direct the small intestine and allow waste to exit the body), the Facility failed to ensure they provided care consistent with professional standards of practice, when on 09/23/24, although nursing was aware Resident #2 did not have ostomy appliances in place over his/her stoma, which was actively secreting stool, no additional nursing interventions were implemented to protect his/her abdominal wound, resulting in fecal matter contamination of his/her abdominal incision, excoriation of surrounding skin, and he/she required transfer and re-admission to the Hospital for treatment. …
F691 citations in Massachusetts
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
Massachusetts cites F691 more often than its own record predicts
1.15 times the share F691 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F691 findings written in Massachusetts, 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 observation, record review and interview for two out of two applicable residents (#15 and #9) out of a total sample of 27 residents and one out of one applicable discharged Resident (#120), out of a total of three discharge residents, the facility failed to implement professional standards of practice for residents who have a colostomy or ileostomy. Specifically: 1. For Resident #15 the facility failed to have physician's orders for the care of his/her ileostomy including changing the appliance, 2. For Resident #9 the facility failed to have orders or documentation to indicate when the colostomy appliance was changed. and 3. The facility failed to ensure orders to indicate when the colostomy appliance is to be changed. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 1.40× |
| 2024 | 0.09% | 1.15× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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