Based on observation, record review, resident interview, and staff interview the facility failed to ensure a resident who has an indwelling urinary catheter receives the care and services needed to ensure the resident did not develop complications related to the indwelling urinary catheter. The facility staff failed to ensure an anchor device was on Resident #105's catheter to prevent it from becoming dislodged. In addition, the nursing staff failed to identify and/or address serious problems with Resident #105's catheter prior to surveyor intervention on two (2) separate occasions on 05/09/23 and again on 05/10/23. In addition Resident #105 suffered a change in mental status which was also not identified by nursing staff until it was pointed out by the surveyor. …
F690 citations in West 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
West Virginia cites F690 less often than its own record predicts
0.34 times the national share — cited less often here than elsewhere.
Of every deficiency written in West 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 West Virginia surveyors wrote
F690 findings written in West 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 resident interview, record review and staff interview, the facility failed to ensure a resident who is incontinent of urine and bowel was assessed and provided appropriate treatment and services to achieve as much normalcy to bladder/bowel functioning as possible and prevent urinary tract infections. Resident #51 experienced harm due to not receiving the appropriate treatment and services to restore as much bladder/bowel function as possible and prevent urinary tract infections. Resident #51 knew when she needed to go to the bathroom. Resident #51 was unable to take herself to the toilet. She required the use of a sit to stand lift for transfers. Resident #51 had to sit in a wet brief at times and had developed urinary tract infections and a rash on her bottom. …
Based on observation, record review, and staff interview, the facility failed to ensure catheter treatment and care was provided within accepted standards of practice. For one (1) of three (3) residents reviewed for the care area of catheters, the urinary collection bag was on the floor. Resident Identifiers: #82. Facility Census: 88. Findings included:a) Resident #82 The facility's policy titled, Catheter Care, with no implementation date given, gave instructions to check that the collection bag was not on the floor. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.01% | 0.62× |
| 2024 | 0.60% | 0.40× |
| 2025 | 0.45% | 0.34× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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