F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews and administrative record review, the facility failed to ensure that one of two
hallways on the Medbridge Unit is maintained and did not have an offensive odor of urine.
The findings included:
An observation on the Medbridge Unit on 01/31/24 beginning at 1:00 PM revealed the smell of a lingering
strong urine odor was noted in the hallway from rooms 172-173 to 178-179. The smell was noted to be the
strongest in rooms 176 - 179.
An interview was conducted on 01/31/24 at approximately 1:05 PM with the Registered Nurse, Staff C, who
confirmed the presence of the offensive odor, by stating, I know. The staff member then returned to her
medication cart.
An interview was conducted on 01/31/24 at approximately 1:07 PM with the Unit Manager, who also
confirmed the presence of the odor and stated she knew who it was.
An interview was conducted on 01/31/24 at approximately 1:15 PM with the Housekeeping Director, who
reported that they clean the rooms and mop the floor. However, when the residents waste their urinal, then
the staff on the floor will need to clean that up. The surveyor requested documentation for cleaning rooms to
verify if the rooms were cleaned. According to the paperwork that was provided which documented the
housekeeping clean-up of rooms, revealed that the staff had cleaned the aforementioned residents' rooms
01/31/24.
An interview was conducted on 01/31/24 at 1:18 PM with the Floor Tech, who reported that he mopped
rooms 174, 176 and 178 at approximately 12:10 PM. However, rooms [ROOM NUMBERS] still smelled of
urine and the smell permeated into the hallway.
Further observations of the rooms beginning at 1:20 PM revealed in room [ROOM NUMBER], there was a
strong urine odor noted inside of the room. Further observation revealed there were urinals sitting on the
floor, next to each resident's nightstand.
room [ROOM NUMBER] also had a strong urine smell. During further observation, it was noted that the
resident in 176 B had a feeding tube, wearing an adult incontinent brief. The resident in 176 A, uses a
urinal.
Random interviews on 01/31/24 beginning at 1:30 PM with residents on the Medbridge Unit also
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105496
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0921
confirmed the persistent presence of the strong urine smell on the unit. One resident stated that he noticed
that the urine smell was stronger as of 01/31/24, than it had been previously.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 2 of 2