Based on interview and document review, the facility failed to properly insert an indwelling urinary catheter and failed to assess and monitor for complications following insertion for 1 of 3 (R1) residents reviewed for catheters. This resulted in harm for R1 when the catheter balloon was improperly inflated in the urethra causing perforation within urethra, hospitalization for hematuria (blood in urine), and a urinary tract infection. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's face sheet dated 2/21/25, identified retention of urine, diabetes mellitus, and chronic kidney disease. …
F690 citations in Minnesota
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
Minnesota cites F690 less often than its own record predicts
0.77 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F690 findings written in Minnesota, 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 document review, the facility failed to ensure a catheter drainage bag (CDB) remained below the level of the bladder and that catheter tubing was free of dependent loops (instances of catheter tubing dipping below the level of the CDB) for 1 of 2 residents (R11) reviewed for catheter care.Findings include:R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnoses of chronic kidney disease and urethral stricture with obstructive uropathy (blockage of the urinary tract which impedes normal urine flow). …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 1.55% | 0.95× |
| 2024 | 1.22% | 0.81× |
| 2025 | 1.05% | 0.77× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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