The facility failed to ensure care and services for one resident (Resident #59) out of a sample of one resident with a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) were provided in accordance with professional standards of practice. The facility allowed Resident #59 to independently perform colostomy care without evidence of a physician order authorizing self-administration of care, without a documented assessment of the resident's competency to safely perform colostomy care, and without ongoing nursing assessment and monitoring of the stoma (opening) and appliance. …
F691 citations in Missouri
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
Missouri cites F691 more often than its own record predicts
1.75 times the share F691 takes of citations nationally.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F691 findings written in Missouri, 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 Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.12% | 1.42× |
| 2024 | 0.10% | 1.29× |
| 2025 | 0.13% | 1.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri 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