Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
of F690 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,469
Every F690 citation surveyors wrote nationally that year.
Facilities cited1,394
Distinct nursing homes with at least one F690 finding.
The harm level
How severely F690 is cited
3.9% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J270.4%
K100.2%
L—
Actual harm
G2093.2%
H70.1%
I—
No harm, potential for more than minimal
D5,55185.9%
E65310.1%
F10.0%
No harm, potential for minimal
A—
B50.1%
C20.0%
Every recorded F690 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F690 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedJuly 23, 2026
Based on interview and record review, the facility failed to meet the medical needs of one sampled resident (Resident #1) out of four sampled residents, who admitted to the facility on [DATE] from the hospital with an indwelling foley catheter (a tube placed to drain the bladder). On 07/09/26, the resident's Urologist (medical doctor and surgeon specializing in diagnosing and treating conditions of the urinary tract) removed the indwelling foley catheter and ordered the resident to be monitored for urinary retention. The facility failed to document any monitoring for post void retention (PVR - urinary output) per policy and as ordered. …
Based on interview and record review the facility failed to provide care for an indwelling urinary catheter (a flexible tube placed inside the bladder to drain urine continuously into an external bag), according to physician orders and plan of care, for 1 of 5 sample residents (Resident 1) reviewed for catheter care. Resident 1, who had a know history of catheter related infections, experienced harm from staff failing to flush their catheter leading to a hospitalization for bacteremia (when bacteria enters the blood stream). This failure placed facility residents at risk of infection, poor clinical outcomes and a decreased quality of life.Findings included. …
D · No harm, potential for more than minimal, isolatedSeptember 12, 2026
Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #20) of 2 residents reviewed for incontinent care and indwelling urinary catheters. The facility failed to ensure Resident #20's indwelling urinary catheter tubing was secured during personal care to prevent dislodgement and injury.This failure could place residents at risk of accidental pulling of the catheter tubing and/or injury.Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter… …
B · No harm, potential for minimal, patternSeptember 15, 2025
Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services for one of two final sampled residents (Resident 11) with an indwelling urinary catheter. * The facility failed to consistently monitor the amount of Resident 11's urinary output related to catheter use as per the physician's order. In addition, the facility failed to monitor the 24-hour total, and weekly evaluation of Resident 11's average intake and output. …
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Cited in the same inspection, not caused by one another.
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