Based on observation, interview, record review, and document review, the facility failed to ensure care orders for nephrostomy tubes were followed for 1 of 40 sampled residents (Resident 77). The deficient practice placed the resident at risk for infection.Findings include: 1)Resident 96 (R96) was admitted on [DATE], with diagnoses including transient cerebral ischemic attack and polyneuropathy.On 04/07/2026 at 8:34 AM, R96 sat up in bed eating breakfast, a medication cup containing eight pills was observed on the meal tray. R96 indicated the nurse left it there so R96 could take the medication when they were ready. …
F691 citations in Nevada
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
Nevada cites F691 more often than its own record predicts
4.33 times the share F691 takes of citations nationally.
Of every deficiency written in Nevada 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 Nevada surveyors wrote
F691 findings written in Nevada, 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 Nevada citations | vs expected |
|---|---|---|
| 2024 | 0.64% | 8.02× |
| 2025 | 0.33% | 4.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada 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