Based interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #1) six residents reviewed for catheter care.- The facility failed to ensure LVN A appropriately monitored and assessed Resident #1 following catheter removal, responded timely to repeated reports of urinary retention, and ensured proper catheter reinsertion resulting in prolonged urinary obstruction, traumatic catheterization, septic shock, hemodynamic instability, and ICU hospitalization.- The facility failed to ensure LVN K removed Resident #1's catheter on 03/20/26 during the day shift when Bladder Training was completed according to… …
F690 citations in Texas
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
Texas cites F690 more often than its own record predicts
1.41 times the share F690 takes of citations nationally.
Of every deficiency written in Texas 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 Texas surveyors wrote
F690 findings written in Texas, 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 record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 residents (Resident #2, Resident #45, and Resident #57) reviewed for urinary catheters. 1. The facility failed to ensure Resident #57 was provided with proper foley catheter and incontinent care on 06/03/2026.The facility failed to ensure the split in Resident #57's penis was routinely assessed.The facility failed to ensure Resident #57's physician and family were notified of the split in his penis. …
Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #20) of 2 residents reviewed for incontinent care and indwelling urinary catheters. The facility failed to ensure Resident #20's indwelling urinary catheter tubing was secured during personal care to prevent dislodgement and injury.This failure could place residents at risk of accidental pulling of the catheter tubing and/or injury.Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter… …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 1.74% | 1.07× |
| 2024 | 2.13% | 1.42× |
| 2025 | 1.91% | 1.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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