Inspection·July 9, 2021

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 observation, interviews and record review, the facility failed to ensure that residents with an indwelling catheter were assessed for removal of the catheter as soon as possible for one (Resident #52) of seven residents with Foley catheters, out of a total sample of 38 residents. Failure to assess residents for indwelling catheter removal predisposes residents to catheter acquired urinary tract infections (CAUTI). The findings include: During the initial tour on 7/6/21 at 12:52 PM, Resident #52 was observed lying in the bed. The Foley catheter tubing was draining clear yellow liquid with an infusion pump at bedside. On 7/6/21 at 12:55 PM, Resident #52 stated that she had just completed the antibiotic therapy for urinary tract infection (UTI). She added that the facility does not change her catheter per physician orders and certified nursing assistants do not empty the bag often. Record review indicated that Resident #52 was admitted to the facility on [DATE]. Diagnoses included COVID 19, type 2 diabetes, morbid obesity due to excess calories, and UTI. Physician orders revealed: Change Foley catheter bag every 2 weeks, Change Foley catheter every month, Foley catheter care and measure output every shift, Change Foley catheter and bag PRN per protocol. Review of Resident #52's care plan revealed that the resident was admitted with a Foley catheter in place due to stage 4 sacral ulcer. She is continent of bowel with interventions to monitor for signs and symptoms of UTI. Care plan for stage 4 sacral pressure ulcer indicated that it would be resolved on 2/2/21. (Photographic evidence obtained) A review of the Quarterly minimum date set (MDS) dated [DATE], showed that Resident #52 had a brief interview of mental status (BIMS) score of 15, indicating resident was cognitively intact. Resident was assessed to require extensive assistance with bed mobility, total dependence for transfer, extensive assistance for toilet use and independent for eating; had an indwelling catheter, continent of bowel and no pressure injuries. On 7/9/21 at 12:34 PM, Employee I, Licensed Practical Nurse (LPN) was asked if Resident #52 had any open areas. He stated he was not sure, so he checked the chart and confirmed the resident had orders for A&D ointments. He then contacted the wound care nurse and stated that resident had no wounds. When he was asked if Resident #52 have any indication/diagnosis for the catheter, Employee I, checked the resident's clinical record and acknowledged he did not. He then contacted the Assistant Director of Nursing (ADON) for assistance. (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 7 Event ID: 105570 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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)