Based on policy review, medical record review, and interview the facility failed to administer treatment and services to restore normal bowel function for 2 Residents (#2 and #7) of 7 Residents reviewed for bowel protocol placing both Residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a Resident). On [DATE] Resident #2 was diagnosed with severe fecal impaction after being transferred to a local emergency room after vomiting what the facility staff described as black slime. Resident #2 expired shortly after arrival to the hospital. …
F690 citations in Tennessee
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
Tennessee cites F690 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in Tennessee 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 Tennessee surveyors wrote
F690 findings written in Tennessee, 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 policy review, medical record review, observation and interview, the facility failed to provide appropriate care and services for residents with an indwelling catheter (a tube in the bladder that drains urine) for 2 of 3 residents (Resident #30 and #304) reviewed for indwelling catheters. The facility's failure to implement interventions to prevent pressure and/or secure catheter tubing resulted in Actual Harm when Resident #30 developed a pressure ulcer related to the catheter tubing. The findings include: 1. …
Based on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to follow physician's orders, provide care and services, care plan, and accurately code the Minimum Data Set (MDS) assessment for an indwelling urinary catheter for 1 of 2 (Resident #3) sampled residents reviewed for the use of an indwelling urinary catheters. The findings include: 1. …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 1.65% | 1.02× |
| 2024 | 0.73% | 0.49× |
| 2025 | 1.27% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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