Based on review of facility policy and procedure, clinical record review, and staff interviews, it was determined the facility failed to provide adequate urinary catheter care for four of six residents reviewed (Residents 6, 8, 28, and 47) resulting in actual harm for three of six residents who contracted urinary tract infections requiring subsequent hospitalizations (Resident 6, 28 and 47).Findings include: Review of the facility's policy, Catheter Care, Urinary (revised September 2014), revealed documentation of catheter care should be documented in the resident's medical record. This documentation should include the date and time catheter care was given, the name of the staff providing the catheter care, and all assessment data obtained during catheter care. …
F690 citations in Pennsylvania
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
Pennsylvania cites F690 less often than its own record predicts
0.99 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F690 findings written in Pennsylvania, 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 facility policy review, clinical record review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure a resident with an indwelling catheter receives appropriate treatment and services to prevent urinary tract infections for two of two residents reviewed for having an indwelling catheter (Resident 6 and 10).Findings include: Review of facility policy, titled Prevention of Catheter-Associated Urinary Tract Infections last reviewed January 2026, read, in part, Only persons (nursing home personnel, family members, or residents themselves) who have been trained in and demonstrate knowledge of the correct maintenance techniques are allowed to handle catheters or provide catheter care. …
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to provide appropriate care for two of 22 residents reviewed who had an indwelling urinary catheter (Residents 4, 18). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated October 18, 2023, revealed that the resident was cognitively intact, was independent for personal hygiene needs, had an indwelling catheter (a tube placed and held in the bladder to drain urine), and had diagnosis that included paraplegia (paralysis of the legs and lower body) and neurogenic bladder (problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 1.62% | 0.99× |
| 2024 | 1.69% | 1.13× |
| 2025 | 1.35% | 0.99× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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