Health inspection·July 9, 2025

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 interview and record review, the facility failed to appropriate services to a resident who is incontinent of bladder, to prevent urinary tract infections for 1 of 3 sampled residents reviewed for incontinence (Resident # 1). The findings included:A record review revealed Resident #1 was admitted on [DATE] with diagnoses that included Cerebral Infarction, Dysphagia, Encounter for Surgical Aftercare following surgery of the Circulatory System, Chronic Obstructive Pulmonary Disease (COPD), Chronic Vascular Disorders of the Intestine, and Gastroesophageal Reflux Disease. A review of the most recent Minimum Data Set (MDS) assessment under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 15 indicating Resident #1 had good cognitive function. Section GG revealed Resident #1 had impairment on one side of the lower extremity, and was dependent on toileting hygiene, shower, bathing, and lower body dressing. Section N revealed Resident #1 was receiving diuretic (a medication that induces frequent urination). In an interview with Staff A, RN when asked if Certified Nursing Assistants (CNAs) turn, reposition, and provide toileting care for resident's that would help them prevent urinary tract infections, responded, yes and I frequently make rounds, and make sure all my residents are cared for in those areas. When she was asked if she documents the turning, repositioning and toileting care of residents, she responded, Yes, in the progress notes. When she was asked if CNAs document the toileting, turning and repositioning of residents, responded, Yes, they document in the Point of Care (POC- an electronic system in the facility where CNAs document their tasks). When she was asked how she knows if a resident has symptoms of urinary tract infection, she responded, The resident's pee is very bad and smells funny. When asked when and where she documents her assessments, she responded, I document in the progress notes. When asked what she documents, she responded, When I suspect UTI, I call the doctor. I will report resident's symptoms such as burning sensation, and cloudy urine output. I will also collect the urine, and let the doctor know, in case he orders a urine test. She added that she also documents the UTI symptoms in the progress notes. A review of June 2025 nursing progress notes did not reveal any notes regarding urinary tract, and perineal care assessment and symptoms monitoring by Nurses for Resident #1. In an interview with Staff E, Certified Nursing Assistant (CNA), when asked if she documents the performed tasks in the computer, responded, Yes, I document them under the tasks section of the POC. When she was asked how often she provides perineal care to prevent UTI to her assigned residents, she responded, Yes, I do it every two hours. In a continuing interview with Staff E, CNA on 07/09/25 at 2:26 PM, when she was asked regarding female resident's peri care, responded, she would wipe from the top going down. She added she performs peri care at least every 2 hours and that I document every time I perform a resident's peri-care. In an interview with Staff D, CNA on 07/09/25 at 3:02 PM, when asked how often she provides perineal care, and toileting hygiene to a resident, responded that she performs it every two hours. When she was shown the document Page 1 of 2 105476 105476 07/09/2025 Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provided by the DON, she admitted that one peri care was provided for Resident #1 during her shifts on 06/10/25 and 06/11/25. An additional review of the document titled, Documentation Survey Report v2, dated 06/25, provided by the DON, revealed Resident #1's bladder incontinence care and hygiene toileting care performed by CNAs on 06/07/25 until 06/11/25 revealed, she obtained both care at the same time, once every shift. In an interview with the Infection Preventionist Registered Nurse (RN) on 07/09/25 at 2:00 PM, she stated she heard of Resident #1's admission through the morning report which occurs daily, but she did not see the resident. She stated she did not write any note regarding Resident #1's admission and found out later about the intravenous (IV) line and the leukocytosis (a condition where white blood cell count is elevated indicating the resident's body is fighting for off infection or inflammation). When she was asked why the resident had an IV access line upon admission, she responded that she did not know why. When asked what kind of precautions she applied for leukocytosis and the IV access line, she did not respond. She stated she did not know about the resident until after the resident was discharged from the facility. When she was asked about her Infection Prevention Control responsibility for newly admitted residents, she did not respond. When she was asked about the names of residents who had a facility acquired UTI in June 2025, she stated she will submit the information later. At the end of this survey, no names were submitted. In an interview with the Director of Nursing (DON) on 07/09/25 at 5:30 PM, when asked about the names of residents with facility acquired UTI's which was first asked during the entrance conference, she responded, that the Infection Control Preventionist RN had it. In an interview with the Medical Director on 07/09/25 at 5:49 PM, when he was asked if he had followed the hospital's discharge recommendation for Resident #1 upon entrance to the facility, responded, I did immediately order a CBC (complete blood count) with differential consistent with the hospital theory of leukocytosis. He added. The resident was seen by an Infection Specialist at the hospital. When Resident #1 was discharged from the hospital on [DATE] and was admitted to the facility, she showed no clinical evidence of infection. When he was asked if the resident acquired the UTI in the facility, he stated, Must be but added, The white blood cell count (WBC) went up due to steroids. It did come down later. He added that on 06/12/25, Resident #1 went down and was immediately sent to the hospital. He added that, Unfortunately, she developed a UTI. 105476 Page 2 of 2