Based on observations, interviews, and records reviewed, for one Resident (#36), of 18 sampled residents, the facility failed to provide Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag to drain urine from the bladder) care and management consistent with professional standards of practice. Specifically, for Resident #36, the facility failed to: -Ensure his/her Foley catheter was properly positioned to ensure adequate drainage from the bladder, -Document care and maintenance of a Foley catheter, -Implement provider orders for Intake and Output (I&O) monitoring to ensure adequate output, and -Notify his/her provider of an abnormal radiology report resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong… …
F690 citations in Massachusetts
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
Massachusetts cites F690 more often than its own record predicts
1.14 times the share F690 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F690 findings written in Massachusetts, 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 observations, record reviews, and interviews, the facility failed to ensure residents admitted with an indwelling catheter were assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated continued catheter use is necessary, for one Resident (#110) out of a total sample of 23 residents. Findings include:According to the Resident Assessment Instrument (RAI- a manual used to for the guidance for the Minimum Data Set assessment, which is required by the Centers for Medicare and Medicaid recipients in skilled nursing facilities): -Indwelling catheters should not be used unless there is valid medical justification. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 1.51% | 0.93× |
| 2024 | 1.40% | 0.94× |
| 2025 | 1.54% | 1.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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