F 0690
Level of Harm - Minimal harm
or potential for actual harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on interview, record review, and observation the facility failed to perform urinary catheter care to
professional standards for 1 of 1 sampled residents (Resident #201).
Residents Affected - Few
Findings included:
The policy, subtitled Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) (2019) has a list of
instructions on preventing CAUTI. Item #17 states: Do not clean the periurethral area with antiseptic to
prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during
daily bathing or showering) is sufficient.
The policy titled Catheter Care, Urinary (revised 2014) has a subparagraph titled Steps in the Procedure
with the following steps:
7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and
towel dry.
16. For a male resident: Use a washcloth with warm water and soap to cleanse around the meatus.
Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth
with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique.
Return the foreskin [when present] to normal position.
17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion
site to approximately four inches outward.
18. Secure catheter utilizing a leg band.
On 04/12/23 at 10:57 AM, an observation of indwelling urinary catheter care for Resident #201 was made
of Staff A, a Certified Nursing Assistant (CNA) who has been employed by the facility for 1 year. The CNA
put on her gown. Staff A assisted Resident #201 from his wheelchair to his bed. There was waterproof
padding laid out on the bed. As Staff A was moving the resident to his bed it was noted that Staff A had
forgotten to remove the bedside catheter drain bag from the dignity bag attached to the wheelchair. This put
an extra strain on the catheter tubing and subsequently Resident #201's genitals. Staff A realized the
problem and corrected the issue. Staff A removed Resident #201's pants and opened the resident's
disposable under garments. There was a red stain on the front of the undergarment that appeared to be
blood. The catheter tubing was not secured to the resident's leg. Staff A covered the resident with a towel.
Staff A washed her hands, put on gloves, and filled a wash basin with water. Staff A was about to place the
wash basin on the bed then asked Resident #201's Private
(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:
105598
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
105598
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbours Edge
401 E Linton Blvd
Delray Beach, FL 33483
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
Duty Aide (PDA) to roll the overbed table over to Staff A. Staff A placed the basin on the overbed table. Staff
A took the washcloth she placed in the basin and rung it out over the resident's perineal area. Staff A
washed the resident using a wash cloth without paying attention to the urinary meatus or using appropriate
technique. Staff A removed alcohol wipes from her pocket and used an alcohol wipe to clean the tubing
from the meatus outward. The resident expressed discomfort from the alcohol wipe stating he had
sensitivity in the area. Staff A repositioned the resident on his right side. Staff A used a clean, disposable
wash cloth to clean the resident's posterior perineal region wiping from front to back. Staff A changed the
gravity bag used at night to a leg bag secured to the resident's left leg with two straps, which were supplied
with the leg bag. Staff A placed the bedside drainage bag in the bathroom trash without emptying the bag
or measuring the urine. Staff A replaced the resident's disposable under garments and the resident's
private duty aid finished dressing the resident. Staff A removed her gown and gloves, disposed of them in
the trash and washed her hands. After the procedure Staff A was asked if she had anything to report to the
nurse and Staff A stated she would report the output in the catheter bag and the blood noted on the
undergarment.
Event ID:
Facility ID:
105598
If continuation sheet
Page 2 of 2
