Based on interview and record review, the facility failed to assess and treat a resident's urinary catheter and follow-up on continued hematuria resulting in immediate jeopardy when the resident with a history of UTI and septic shock did not have a follow-up with a Urologist for continued hematuria and blood clots, had a change in condition with his urinary catheter, and was sent to the hospital several hours later in septic shock and respiratory failure for 1 of 5 residents reviewed for change in condition (Resident B). The immediate jeopardy began on [DATE] when Resident B, with a history of urinary catheter, severe sepsis with septic shock, and urinary tract infection (UTI) on [DATE], had a distended abdomen and low urine output in the foley drain bag on [DATE] at 10:19 p.m. …
F690 citations in Indiana
Incontinence and catheter care · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F690 more often than its own record predicts
1.72 times the share F690 takes of citations nationally.
Of every deficiency written in Indiana in 2025, this is the portion that was F690.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F690 findings written in Indiana, 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 interview and record review, the facility failed to ensure a foley catheter placement was documented and follow-up assessments were completed after a change in urine characteristics were observed for 1 of 3 residents reviewed for catheters. (Resident B) This deficient practice resulted in Resident B being admitted to the hospital with urethral trauma.Findings include:During an interview, on 12/11/25 at 3:04 p.m., Resident B's family indicated the physician in the emergency room had indicated Resident B's catheter was inserted at the facility incorrectly. She was told a nursing student placed the catheter; the balloon was in his urethra and damaged it.The clinical record for Resident B was completed on 12/11/25 at 10:32 a.m. …
Based on interview and record review, the facility failed to provide catheter care as ordered by the physician for 1 of 4 residents reviewed for catheter care. (Resident C) Findings include:The clinical record for Resident C was reviewed on 7/21/26 at 1:36 p.m. The diagnoses included, but were not limited to, intellectual disabilities, urinary tract infections, and obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward into the kidneys). An admission Minimum Data Set (MDS) assessment, dated 5/9/26, indicated Resident C was severely cognitively impaired and had no behaviors for rejection of care. A physician's order, dated 5/18/26, indicated urinary catheter care every shift. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 2.80% | 1.72× |
| 2024 | 2.36% | 1.57× |
| 2025 | 2.33% | 1.72× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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