Health inspection·November 13, 2024

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, record review, and interview, the facility failed to ensure proper indwelling urinary catheter care and services for 1 of 3 sampled residents, as evidenced by the failure to assess for and or attempt to discontinue the indwelling urinary catheter for Resident #1. The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE], after hospitalization for back surgery. Review of the hospital record revealed the indwelling urinary catheter was placed at the time of the surgery. The hospital discharge instructions lacked any documentation related to the indwelling urinary catheter. The hospital record lacked any documented attempt at removal of the device. Review of the transfer form dated 09/04/24 from the hospital documented Resident #1 had a Foley catheter (indwelling urinary catheter) in place but lacked any indication for use and lacked information as to if the hospital made an attempt to remove the device. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating intact cognition. This MDS also documented the resident had an indwelling urinary catheter for neurogenic bladder, as did an order dated 09/06/24. The admission nursing assessment dated [DATE] documented Resident #1 was admitted with the indwelling urinary catheter. Review of all nursing and physician progress notes, along with all physician orders, lacked any documented assessment to remove the indwelling urinary catheter, or rationale as to why it needed to remain. The record also lacked a documented voiding trial, a process where the urinary catheter would be removed to allow the resident to urinate. The progress notes and orders also lacked any need for a urinary consult. Review of the record revealed an order for a surgical follow-up appointment scheduled for 09/26/24 at the physician's office. A progress note dated 09/26/24 at 2:15 PM documented Resident #1 was transported to the hospital following a doctor's appointment. Review of the post-operative progress note from the Resident's follow-up appointment documented, in part, that Resident #1 still had the Foley catheter in place. This note revealed Resident #1 told the nursing staff and doctors at the SNF (skilled nursing facility) that the catheter was meant to be removed and that she had not had any voiding trial. This note documented the Foley catheter was to be removed two to three days after admission to the facility. Page 1 of 3 106091 106091 11/13/2024 Luxe at Wellington Rehabilitation Center The 10330 Nuvista Avenue Wellington, FL 33414

F 0690 Level of Harm - Minimal harm or potential for actual harm During a side-by-side review of the record and interview on 11/13/24 at 4:47 PM, when asked if there had been an assessment or attempt to remove the indwelling urinary catheter for Resident #1, the First Floor Unit Manager stated she could not find anything in the electronic record. When asked the process to ensure a resident does not have a urinary catheter longer than needed, the Unit Manager stated typically the physician would order a voiding trial shortly after admission. Residents Affected - Few 106091 Page 2 of 3 106091 11/13/2024 Luxe at Wellington Rehabilitation Center The 10330 Nuvista Avenue Wellington, FL 33414

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and interview, the facility failed to ensure proper care and services for the intravenous line for 1 of 1 sampled resident, as evidenced by the lack of dressing changes as per order for Resident #2. Residents Affected - Few The findings included: Review of the policy Central Lines revised 05/2024 documented, in part, Procedure: . 2. Ensure infection control standards are maintained during the care of the central line including but not limited to: a. Change dressing routinely and per physician orders. Review of the policy Documentation revised 01/2024 documented, in part, Procedure: . 4. documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the orders revealed the resident had had several peripheral IVs (intravenous access devices) placed throughout his stay at the facility, with the most recent being a midline (specific type of central line intravenous catheter) that was placed on 10/28/24. This order instructed the nurses to change the dressing every Tuesday and as needed using sterile technique. An order dated 10/28/24 also instructed the nurses to flush the midline twice daily with normal saline. Review of the Medication Administration Record (MAR) documented the same nurse changed the midline dressing on 10/29/24, 11/05/24, and 11/12/24. The MARs also documented nurses were flushing the midline twice daily starting on 10/28/24 through the survey date. During an observation on 11/13/24 at 12:10 PM, Resident #2 was in bed and the midline IV access was noted to his right upper arm. The top edge of the dressing was loose and pulling back from the skin. The label on the dressing had a nurse's initials, different from the nurse who had documented the provision of care on the MAR, and the date was from October, but unable to read the specific day of the month. Review of the employee roster revealed there was no current facility nurse with the initials documented on the midline dressing, which would indicate the observed dressing was from the technician who inserted the line on 10/28/24. During a side-by-side review of the record and interview, when told of the observation of the midline dressing for Resident #2, the First Floor Unit Manager stated she agreed with the findings. The Unit Manager stated the nurses were flushing the line twice daily and should have noted the need for a new dressing for the midline. 106091 Page 3 of 3