Based on interview and record review, the facility did not ensure 1 of 1 resident (R3) received the necessary comprehensive assessment or care and treatment for indwelling catheter use. R3 was admitted to the facility on [DATE] with urinary incontinence and at some point, after the admission, the facility was unable to determine when, R3 received an indwelling catheter. There was no physician order for the indwelling catheter, no comprehensive assessment of the catheter and no comprehensive care plan directing the care and treatment of the catheter. On 5/31/25, R3 was discharged to the hospital for a change in condition and was diagnosed with septic shock secondary to UTI (urinary tract infection). …
F690 citations in Wisconsin
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
Wisconsin cites F690 more often than its own record predicts
1.29 times the share F690 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F690 findings written in Wisconsin, 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 interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 3 of 3 residents (R4) reviewed.-R4's suprapubic catheter output was not monitored per physician's order and assessments not completed per professional standards of practice. R4 was transferred to the hospital on [DATE] after 2 days of increased incontinence, and hospitalized for four days with a Urinary Tract Infection. …
Based on observation, interview and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 2 of 2 residents (R14 and R5) reviewed for catheters out of a total sample of 15. R14's catheter drainage bag touching and dragging on the floor.R14 had an incomplete care plan directing nursing staff on catheter care.R14 had no doctor's orders specific to size of catheter and when to change the catheter. Findings:R14 was admitted to the facility on [DATE] with a Brief Interview of Mental Status Score of 13/15 which indicated R14 was cognitively intact. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 1.84% | 1.13× |
| 2024 | 1.96% | 1.30× |
| 2025 | 1.75% | 1.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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