F691 in Oregon. Pick another state for the same tag.
Against expectation — 2025
Oregon cites F691 more often than its own record predicts
Versus expected share1.39×
1.39 times the share F691 takes of citations nationally.
Share of Oregon citations0.10%
Of every deficiency written in Oregon in 2025, this is the portion that was F691.
Oregon0.10%
National0.08%
Share of all citations that were F691.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F691 findings written in Oregon, 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.
G · Actual harm, isolatedFebruary 2, 2026
Based on observation, interview and record review it was determined the facility failed to provide necessary care and services for ileostomy (surgical opening in the abdominal wall that provides a way for the end of the small intestine to release stool) care for 1 of 1 sampled resident (#13) reviewed for bladder and bowel incontinence. This failure resulted in the Resident 13 experiencing excoriation (a skin injury involving the removal of skin), increased pain and discomfort, unmet ileostomy care needs, a delay in medical care and psychosocial harm. …
D · No harm, potential for more than minimal, isolatedDecember 19, 2025
Based on interview and record review it was determined that the facility failed to provide colostomy care according to professional standards for 1 of 2 sampled residents (# 8). This placed residents at risk for skin breakdown and infection. Findings include:Resident 8 admitted to the facility with diagnoses including renal failure. Resident 8's 8/27/25 Care Plan indicated the resident's colostomy bag was to be changed as needed per the resident's provider order. Resident 8's 9/22/25 Physician Orders indicated the resident used a colostomy bag. …
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