Based on interview and record review, the facility failed to ensure provider orders were consistently followed to track ostomy (a surgically placed opening [stoma] in the abdomen to allow body waste to pass into a collection bag) output, teach the resident to manage their ostomy independently, consistently assess and monitor skin around the stoma and provide and document ostomy care consistent with professional standards for 1 of 1 resident (Resident 1) reviewed for ostomy care. Resident 1 experienced harm when they developed excoriation (skin breakdown), redness and weeping, around their ostomy so facility staff were unable to securely adhere the ostomy bag to the skin and required the resident's transfer to the hospital for evaluation and treatment. …
F691 citations in Washington
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
Washington cites F691 more often than its own record predicts
1.85 times the share F691 takes of citations nationally.
Of every deficiency written in Washington 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 Washington surveyors wrote
F691 findings written in Washington, 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.
Based on observation, interview, and record review, the facility failed to ensure care was provided in accordance with professional standards, by not providing urostomy (urinary diversion, which is a surgical procedure to create an opening (stoma) on the abdomen to allow urine to exit the body when the bladder is not functioning or has been removed. The urine is then collected in a pouch attached to the stoma) supplies for 1 of 1 sample resident (Resident 10) reviewed for urostomy care. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Resident 10 was admitted to the facility on [DATE] with a diagnosis of acute pancreatitis (inflammation of the pancreas). …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.66× |
| 2024 | 0.09% | 1.15× |
| 2025 | 0.14% | 1.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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