Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents who required nephrostomy tubes (a tube that drains urine from the kidney through an opening in the skin) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #161) reviewed. Specifically, Resident #161 had a nephrostomy tube and the physician orders did not include specific instructions to document the description of the output, when to change the drainage bag, to monitor for tube patency or blockage, and to monitor for signs and symptoms of infection; the care plan did not include care instructions or indicate what to monitor for and report; and staff were unsure if licensed practical nurses or certified… …
F691 citations in New York
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
New York cites F691 less often than its own record predicts
0.48 times the national share — cited less often here than elsewhere.
Of every deficiency written in New York 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 New York surveyors wrote
F691 findings written in New York, 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 New York citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.64× |
| 2025 | 0.04% | 0.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York 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