Health inspection·January 29, 2025

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, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent the UTI for two of three sampled residents (Residents1 and 2) reviewed for the use of the indwelling urinary catheters. * The facility failed to ensure Resident 1's indwelling urinary catheter drainage bag was not laying on the floor. * The facility failed to ensure the physician was notified when Resident 2 had a change in condition due to frequent leakage of the indwelling urinary catheter and clarify the size of the indwelling urinary catheter prior to be inserted. These failures had the potential for not providing the necessary care and services and posed a risk for adverse complications related to the indwelling urinary catheter use. Findings: 1. Review of the CDC's guidelines titled Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guideline dated 4/2024, showed urinary tract infections are the most common type of healthcare associated infection. CAUTI has been associated with increased morbidity, mortality, hospital cost, and length of stay. The section titled Proper Techniques for Urinary Catheter Maintenance, showed to keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Medical record review for Resident 1 was initiated on 1/28/25. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed the BIMS score of 7 (severe cognitive impairment). Review of Resident 1's Nurses Progress Note dated 1/25/25, showed Resident 1 had a UTI and was started on antibiotics (a medication used to treat infection). Review of Resident 1's Order Summary Report as of 1/29/25, showed the following physician's orders: - on 1/14/25, for an indwelling urinary catheter size 16 Fr Balloon size/10 ml, change for blockage, leaking, pulled out, excessive sedimentation; and to change the urinary catheter drainage bag as needed and with every change of the indwelling urinary catheter, and every shift care for the (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 3 Event ID: 055121 Printed: 05/15/2026 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 055121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pelican Ridge Post Acute 466 Flagship Road Newport Beach, CA 92663 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)