Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for a urostomy consistent with professional standards of practice for one of 80 residents in the survey sample, Resident #125.The findings include:For Resident #125 (R125), the facility staff failed to maintain a urinary collection bag in a sanitary manner. R125 was admitted to the facility with diagnoses that included but were not limited to urostomy (1) and malignant neoplasm of bladder (2).On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 1/29/2026, the resident scored 15 out of 15 on the brief interview for mental status (BIMS)… …
F691 citations in Virginia
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 — 2024
Virginia cites F691 more often than its own record predicts
4.69 times the share F691 takes of citations nationally.
Of every deficiency written in Virginia in 2024, 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 Virginia surveyors wrote
F691 findings written in Virginia, 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 Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.13% | 1.62× |
| 2024 | 0.37% | 4.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia 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