Based on review clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of 40 residents reviewed (Resident 16).Findings include:The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated January 22, 2026, colostomy care will be provided per physician orders to provide the stoma with good skin care and check the condition of the stoma and surrounding skin.An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16 dated March 17, 2025,indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had medical diagnosis… …
F691 citations in Pennsylvania
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
Pennsylvania cites F691 more often than its own record predicts
2.20 times the share F691 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F691 findings written in Pennsylvania, 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 Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 3.12× |
| 2024 | 0.13% | 1.63× |
| 2025 | 0.17% | 2.20× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania 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