Health inspection·October 8, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete admission, a resident who is at risk for skin breakdown will have the necessary supplies to prevent the development of pressure ulcer. She added that they have weekly skin check, where the Nurse will go in and observe the body for any new areas forming and document the findings in the computer, on skin observation under the assessment tab. When she was asked if it is possible to have stage 4 pressure ulcer after a month of staying in the facility, she stated that it would first start with visible skin issues like redness, excoriation, deteriorating, then stage 1, but usually not stage 4 right away. She had not witnessed a resident who did not have any skin opening during admission and then a month later turned into stage 4 pressure ulcer. When she was asked if there was a facility acquired pressure ulcer in September 2025, she responded, Resident #1, because this resident came in with scar tissue on the sacrum, which was closed, and with no drainage. I did not take a picture of the sacrum during admission, and I wrote buttocks on her nursing admission skin assessment which was electronically submitted on 8/20/25. I performed the skin assessment on 8/20/25, but I corrected the word buttocks into sacrum later. She added that she initiated preventive measures like barrier cream, offloading measures, wedges and air mattress, but wedges and air mattress were not provided to Resident #1 because the resident had no open wound on admission. When she was asked if there were risk for the development of pressure ulcer for this resident, she responded that this resident had a risk of developing pressure ulcer. She ordered the air mattress and wedges on 09/09/25, which was approximately 3 weeks after Resident #1's admission to the facility. She ordered them because the resident was not thriving. The resident was refusing to eat, drink, refusing clean up, and frequently with closed mouth. The resident had sacral excoriation only on 9/9/25, then stage 1 within the same week, according to Wound Care LPN. On 9/18/25, staff stated Resident #1's sacral wound was Stage 4. Staff added that the exacerbation of sacral wound was related to generalized decline of resident, and it was according to the wound physician. The doctor did not stage the wound of Resident #1 according to the Wound Care LPN. She admitted that she did not intervene immediately at admission. She added that according to the wound physician, no amount of intervention can prevent the occurrence of Stage 4 pressure ulcer, a few weeks after admission to the facility. On 8/20/25, she wrote the admission skin assessment, but she did not see the resident again until 9/2/25. She admitted that she wrote 3 late entries in the nursing progress notes. She added that she saw the resident after a nurse called her that Resident #1's skin on the sacral area was starting to break down. When she was asked why there were 3 late entries in the nursing progress notes regarding her skin assessment, she responded, Because I was not doing my weekly skin notes. When she was asked why she was not doing the weekly skin notes, she responded, I do not know. In an interview conducted with Staff B, an LPN on 10/7/25 at 12:42 PM, when she was asked regarding Resident #1's pressure ulcer, she stated she did not remember, but she remembered this resident was refusing care frequently, although she did not remember when Resident #1 started to refuse care. When she was asked if she monitored the skin weekly, she responded, Yes. When she was asked how she prevents pressure ulcer development, she responded, I follow the facility's policy, use barrier cream, wash and dry the sacral area, and perform incontinent change often. I will ask the staff CNAs to turn and reposition the resident. She added that she will use pillows to take pressure off the sacral area and any bony prominences. When she was asked if she monitors the CNAs when they were doing the turning and repositioning tasks, she responded, Sometimes. Event ID: Facility ID: 105237 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broward Oaks Nursing and Rehabilitation 7751 W Broward Blvd Plantation, FL 33324 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to follow the professional standards of practice for the care and management of an indwelling urinary catheter and failed to follow their own policy for catheter care for 2 of 2 residents reviewed for urinary care (Resident #1 and Resident #3). The findings included:According to the Center for Disease Control and Prevention (CDC), in the non-acute care setting. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (p.12). Education and performance feedback regarding appropriate use, hand hygiene, and catheter care (p.15). https://www.cdc.gov/infection-control/media/pdfs/Guideline-CAUTI-H.pdf According to the facility's policy titled, Catheter Care, implemented on 12/17/17, it documented that it is the policy of this facility to ensure that residents with indwelling catheter receive appropriate care and maintain their dignity and privacy when indwelling catheters are in use. Catheter care will be performed every shift and as needed by nursing personnel. 1) A record review revealed Resident #1 was admitted to the facility on [DATE] and was transferred to a hospital on 9/26/25. The admitting diagnoses included in part, Cerebral Aneurysm, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Reflux Uropathy, Essential Hypertension and Spondylosis without Myelopathy or Radiculopathy of the Lumbar region. A review of admission Minimum Data Set (MDS) assessment dated [DATE] under Section C for the Brief Interview of Mental Status (BIMS) revealed a score of 14, indicating Resident #1 had no cognitive impairment. Section GG documented this resident was staff dependent on eating, personal hygiene, toileting, and upper and lower body dressing. Section H revealed a yes response to indwelling catheter. An additional review of physician order dated 8/4/25, documented to provide (Foley) indwelling catheter care, every shift, and secure catheter with a holder to prevent migration, every shift. A further review of orders did not include Enhanced Barrier Precaution (EBP), when the urinary catheter care was ordered. A record review of facility's EBP policy with implementation date of 11/20/21 revealed an order for EBP will be obtained for residents with wounds and or indwelling medical devices (e.g. urinary catheter) regardless of Multiple Drug-Resistant Organism (MDRO) colonization status. In an interview conducted with the Infection Control Licensed Practical Nurse on 10/07/25 at 1:35 PM, when she was asked if a resident with a urinary catheter should be under EBP guidelines, she responded, Yes. When she was asked when the resident will be under EBP guidelines, she responded, as soon as the resident was ordered to have a urinary catheter. A further review of nursing care plan revealed that the EBP focus related to urinary catheter was not initiated until 9/26/25, indicating it was added approximately 7 weeks after Resident #1's admission to the facility. 2) A record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Non-Traumatic Intracerebral Hemorrhage affecting the Left Nondominant Side, Obstructive and Reflux Uropathy, Hypertensive Chronic Kidney Disease and Cognitive Social and Emotional Deficit following Nontraumatic Intracerebral Hemorrhage. A review of the quarterly MDS assessment dated [DATE], under Section C, revealed a BIMS score of 12, indicating Resident #3 had moderate cognitive impairment. Section H revealed a yes response to indwelling catheter. An electronic record review of physician orders dated 8/12/25, documented indwelling urinary catheter of size 16, with inflation balloon of 10 ml (milliliter) sterile water for the diagnosis of Obstructive Uropathy. An additional review of physician order dated 8/4/25, documented to provide (Foley) indwelling catheter care, every shift, and secure catheter with a holder to prevent migration, every shift. During a urinary care observation and interview conducted on 10/7/25 at 2:58 PM, with Staff G, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105237 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broward Oaks Nursing and Rehabilitation 7751 W Broward Blvd Plantation, FL 33324 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Restorative Certified Nursing Assistant (CNA), and Staff I, another CNA, who when asked about the color and the urine consistency, both stated the color was pinkish, cloudy and with sediments noted in the urinary tubing. Additional observation revealed Resident #3's catheter was not secured on the thigh but freely moving when the resident moved. Both staff CNAs stated that the secure lock was not secured and not dated. When Staff I, a CNA was asked if she frequently provides urinary catheter care to Resident #3, she responded, Yes, every time I am assigned to him. When she was asked if the secure system is always attached to the resident's, she responded, Sometimes. When she was asked if she reattaches the secure system (anchor)when it becomes detached, she responded, Nurses do that. When she was asked if she will tell the staff Nurse regarding the detachment of the secure system, she responded, I always tell the Nurse. During the same urinary care observation, Staff I, CNA did not change her gloves from beginning until the end. When she was asked why she kept the same gloves for cleaning the resident's urinary meatus, penis, inner thighs, catheter tubing, bed cover, bed remote control, call light and gown, she did not respond. During another observation on 10/08/25 at 1:30 PM, with Staff F, a Restorative CNA, the same urinary secure system was still detached and not secured to resident's thigh. When the resident was asked if Nurses attached it to him, he responded, No. When the resident was asked if staff perform hand washing before providing him urinary care, he responded, No. A review of September 2025 Medication Administration Record and Treatment Administration Record (TAR) revealed that on 9/24/25 and 9/26/25 during the day shifts, securement of catheter was not done by staff per physician order. A review of physician order dated 10/7/25 at 3:08 PM revealed Cefdinir Capsule 300 milligram (MG), give 1 capsule by mouth every 12 hours for Urinary Tract Infection (UTI) for 7 Days. In an interview conducted with Staff J, a Licensed Practical Nurse (LPN) on 10/08/25 at 2:45 PM, when she was asked if she provides urinary catheter care to Resident #3, she responded, Yes. When she was asked when the last time urinary care was provided for this resident, she responded, I work from 7:00 AM to 3:00 PM, and I still have not provided urinary care for this resident since the beginning of my shift. When she was asked what time she will provide urinary catheter care, she responded, A few minutes before I go home. When she was asked if she had assessed the color and consistency of urine for Resident #3, she responded, 'I have not done it yet. An electronic record review of nursing care plan revealed that catheter care was not initiated until 8/11/25, indicating it was done 7 days later after the physician ordered a urinary catheter for Resident #3, on 8/4/25. An additional review of nursing care plan did not include an EBP intervention for urinary catheter. A further review of September 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that on 9/24/25 and 9/26/25 during day shifts, securement of catheter was not done by staff per physician order. A review of physician order dated 10/7/25 (first day of survey) at 3:08 PM, it revealed Cefdinir Capsule 300 milligram (MG), to give 1 capsule by mouth every 12 hours, for Urinary Tract Infection (UTI) for 7 Days. In an interview conducted with Staff B, an LPN on 10/7/25 at 12:41 PM, when she was asked regarding urinary catheter care and management for residents, she responded, The catheter will be flushed as ordered, and I made sure I follow the facility's policy for catheter care. The urinary catheter care is done by staff, and I must perform them for my assigned residents. She added that she monitors the resident for possible UTI by monitoring symptoms like confusion and complaining of burning in the area. She added that the facility does not wait for fever to occur to indicate infection. She monitors the urine output color, and consistency and encourages resident to drink or make sure to have adequate fluid intake. She added she monitors the catheter frequently during her shift. Event ID: Facility ID: 105237 If continuation sheet Page 4 of 4