3. For Resident #10 (R10), who suffered from quadriplegia and was totally dependent upon facility staff, the facility staff failed to respond to the call bell to provide incontinence care in a timely manner, resulting in psychosocial harm. On 4/3/25 at 9:38 a.m., upon the surveyor's arrival to the south unit, observations revealed multiple call bells/lights engaged. On 4/3/25 at 9:41 a.m., the surveyor entered the room where one of the call lights was engaged as evidenced by a light being illuminated outside the door in the hallway and a beeping auditory sound being heard. R10 acknowledged that he had his call light on and reported he needed to be changed. When asked how long his call light had been on, R10 said, Go look for yourself. …
F690 citations in Virginia
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
Virginia cites F690 less often than its own record predicts
0.73 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia 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 Virginia surveyors wrote
F690 findings written in Virginia, 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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for indwelling urinary catheters for three of 26 residents in the survey sample, Residents #17, #9, and #18. The findings include: 1. For Resident #17 (R17), the facility staff failed to cleanse the resident's nephrostomy (1) tube sites, failed to change nephrostomy tube dressings per physician's orders, and failed to empty nephrostomy tube bags per physician's orders. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.12% | 0.69× |
| 2024 | 1.33% | 0.89× |
| 2025 | 0.99% | 0.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction