The facility reported a census of 42 residents with two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) management. Based on observation, record review, and interview the facility failed to ensure appropriate indwelling urinary catheter care for Resident (R)1. On 12/24/23 at approximately 08:30 PM Licensed Nurse (LN) G flushed R1's indwelling urinary catheter, without a physician order, and used a non-sterile 60 milliliter (ml) syringe from R1's bathroom, which possibly contained some bleach and water mixture (used to clean R1's dependent drainage bag). R1 complained of burning pain immediately upon injecting the flush and LN G realized she performed the flush on the wrong patient. …
F690 citations in Kansas
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
Kansas cites F690 less often than its own record predicts
0.89 times the national share — cited less often here than elsewhere.
Of every deficiency written in Kansas 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 Kansas surveyors wrote
F690 findings written in Kansas, 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 record review, observation, and interview, the facility failed to provide urinary catheter care based on current standards of practice for Resident (R) 1 when the facility failed to unclamp the resident's catheter for approximately 8 hours, which caused the resident pain and discomfort. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), overactive bladder, Stage 4 chronic kidney disease (a disease causing severe kidney damage and waste builds up in the blood), and obstructive and reflux uropathy (a blockage that stops urine flowing normally through the urinary tract… …
Based on observations, interviews, and record review, the facility failed to provide catheter (tube inserted on the bladder to drain urine) care and services consistent with the standard of care for Resident (R) 7 when staff failed to ensure his urine collection bag was maintained below the level of his bladder. Findings included:- R7's Electronic Medical Record (EMR) documented diagnoses of difficulty in walking, lack of coordination, and neuromuscular dysfunction of the bladder. R7's Annual Minimum Data Set (MDS) dated 04/30/2026 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. …
The short window
Recent years
| Year | Share of Kansas citations | vs expected |
|---|---|---|
| 2023 | 2.92% | 1.80× |
| 2024 | 1.98% | 1.32× |
| 2025 | 1.20% | 0.89× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kansas surveyors cite →
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