Health inspection·April 23, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with active wounds and a Peripherally Inserted Central Catheter (PICC) line, for 1 of 6 sampled residents on EBP (Resident #3); and facility failed to implement infection control practices for a resident with a urinary catheter, for 1 of 3 sampled residents (Resident #1.) Residents Affected - Few The findings included: 1) Review of the policy titled Enhanced Barrier Precautions Chapter: Infection Prevention and Control revised 06/13/24 documented Enhanced Barrier Precautions are indicated . 2. Wounds, and/or indwelling medical devices even if the resident is not known to be infected or colonized with a Multi-Drug-Resistant Organism (MDRO). Indwelling devices: Indwelling urinary catheters, Gastronomy-feeding tubes, Central lines including PICC, Midline, tracheostomy tubes . Review of the record revealed Resident #3 was admitted to the facility 04/16/25. A Brief Interview for Mental Status (BIMS) evaluation conducted on 04/17/25 documented the Resident had a BIMS score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the care plan dated 04/17/25 documented Resident #3 is at risk for impairment to skin integrity related to Peripheral Artery Disease (PAD), Diabetes Mellitus (DM). 04/16/24 admitted with R great toe wound/infection. Interventions included Enhanced Barrier Precautions. Review of the current orders revealed Resident #3 had a PICC line and active wounds. Further review revealed the Resident's wounds were located on the right great toe and right heel. Resident #3 had active orders for wound treatments and was currently receiving antibiotics. No active EBP orders were revealed upon record review. During an observation conducted on 04/23/25 at 9:59 AM the Wound Care Nurse was seen inside Resident #3's room. No EBP sign or Personal Protective Equipment (PPE) was observed at the Resident's doorway. At 10:13 AM another attempt was made to observe the Resident, the Wound Care Nurse was still in the room with Resident #3. During an observation and interview conducted on 04/23/25 at 11:50AM, no EBP sign or PPE was observed upon entrance or inside the Resident #3's room. When asked if staff wear a gown when they provide direct care she stated, No, I don't think they wear gowns. Resident #3 stated she had a PICC line and two wounds and she was currently being treated with antibiotics. During an interview on 04/23/25 at 12:29 PM, when asked what Residents should be placed on EBP, the Page 1 of 3 105837 105837 04/23/2025 Boynton Beach Rehabilitation Center 9600 Lawrence Rd Boynton Beach, FL 33436

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Infection Preventionist stated Residents with open wounds, foleys, Intravenous lines (IV) such as midlines and PICC line. When asked why Resident #3 was not on EBP , the Infection Preventionist stated the resident should be on EBP due to the wound and PICC line. She confirmed that it had been her error and thought there was an order. During an interview on 04/23/25 at 1:16 PM, when asked if she was providing care to Resident #3 earlier while in the room, the Wound Care nurse replied No I was just talking to her, she feels comfortable with me. When asked if she knew why the Resident was not on EBP, the Wound Care Nurse stated she didn't know why and thought she was on it. During an interview on 04/23/25 at 1:31 PM the Assistant Director of Nursing (ADON) was made aware of Infection control concerns regarding Resident #3, and the ADON acknowledged with the findings. 2) Review of the Centers for Disease Control and Prevention article titled Summary of Recommendations published 03/25/24 documented, III. Proper Techniques for Urinary Catheter Maintenance . III.B.2. Do not rest bag on the floor. Review of the record revealed Resident #1 was last admitted to the facility 08/26/24.Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. Review of the active orders revealed Resident #1 currently had a suprapubic catheter (a urinary catheter inserted directly into the bladder through a small incision in the lower abdomen, rather than through the urethra.) Review of the Wound PCR Panel revealed that Resident #1 had a positive wound result reported on 03/14/25 to his suprapubic catheter site with suggested treatments. Further review of his record revealed he was treated for this infection with antibiotics. During an observation on 04/23/25 at 9:30 AM, Resident #1's urinary drainage bag was seen resting on the floor. Photographic evidence obtained. During a follow-up observation on 04/23/25 at 12:09 PM, Resident #1's representative was at the bedside feeding the resident. When asked how care was, the representative stated that Resident #1 has had a lot of urinary tract issues lately. When the urinary drainage bag was observed again, it was still resting on the floor. During an interview on 04/23/25 at 12:29 PM, when asked, Upon conducting an initial observation and assessment on a resident who has a urinary catheter, what do you not want to see? The infection preventionist replied I don't want to see a catheter bag on the floor or a catheter above the bladder because that can lead to infection, those two things are very important. When the infection preventionist was shown a picture of Resident #1's catheter bag resting on the floor, she stated she would have to check the policy to see if that was acceptable as it was in a dignity bag. No policy was provided to the surveyor justifying the infection preventionist's comment. During an interview on 04/23/25 at 1:31 PM with the ADON, when made aware of the concerns regarding Resident #1's catheter, the ADON stated it was hard to keep it off the ground due to the bed being in the lowest position. The ADON was made aware two other catheter bags were also observed with the 105837 Page 2 of 3 105837 04/23/2025 Boynton Beach Rehabilitation Center 9600 Lawrence Rd Boynton Beach, FL 33436

F 0880 bed in the lowest position and they were not observed resting on the ground. The ADON agreed how it was still an infection control concern due to the recent infection to the same site. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105837 Page 3 of 3