Based on observation, interview, and document review, the facility failed to ensure physician orders were in place to provide treatment and monitoring for an ostomy (ileostomy) (opening to allow waste to exit the body and be collected in a pouch) for 1 of 1 resident (R5) reviewed for ostomy care. The facilities failure resulted in harm for R5 who continued to exhibit symptoms of redness, severe pain, excoriation (abrasion, breakdown) and infection requiring two courses of antibiotics.Findings include:R5 was admitted to the facility on [DATE]R5's Minimum Data Set (MDS) assessment, dated 09/12/25, identified no cognitive impairment, had limited range of motion of both her upper and lower extremities and R5 required substantial to maximal assistance with personal hygiene. …
F691 citations in Minnesota
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
Minnesota cites F691 more often than its own record predicts
1.54 times the share F691 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F691 findings written in Minnesota, 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 interviews and document review, the facility failed to ensure physician orders were in place to provide treatment and monitoring for a colostomy (opening to allow waste to exit the body and be collected in a pouch) for 1 of 1 resident (R1) reviewed for ostomy care.Findings include: R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated intact cognition and presence of an ostomy (a surgical opening in the colon that allows stool to exit the body through a stoma into an external pouch). R1's diagnoses included paraplegia, malnutrition, and neurogenic bowel (loss of bowel control caused by brain, spinal cord, or nerve problems). …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.06% | 0.79× |
| 2025 | 0.12% | 1.54× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction