Inspection·December 8, 2023

F 0690 Level of Harm - Potential for minimal harm Residents Affected - Some 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 interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) received the incontinence care in a timely manner when Resident 1 waited for an hour to receive care. This failure resulted in Resident 1's incontinence brief to overflow with urine unto the floor, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's assessment showed the resident's care needs included responding to requests for assistance with bathroom/toileting needs promptly in order to maintain continence and residents' dignity. Further review of this document showed physical equipment needs for the facility included lifts. On 12/5/23 at 0945 hours, a telephone interview was conducted with Resident 1's RP. When asked about Resident 1's care, the RP stated on 11/29/23, during the day shift, there was a delay in changing Resident 1's soiled incontinence brief. Per the RP, during this delay, Resident 1 had another episode of urine incontinence. The RP stated on 11/29/23 at 1151 hours, Resident 1 was sitting on her geri-chair with urine overflowing out of her diaper, onto Resident 1's geri-chair, and onto the room floor. The RP stated she placed the paper towels on the floor to soak up Resident 1's overflowed urine. The RP stated Resident 1 waited for an hour before getting her incontinence brief changed. Medical record review for Resident 1 was initiated on 12/12/23. Resident 1 was admitted to the facility on [DATE], and discharged to another facility on 12/6/23. Review of Resident 1's History & Physical examination dated 9/28/23, showed Resident 1's diagnoses included post status brain injury and spinal cord fractures. Review of Resident 1's initial MDS dated [DATE] showed Resident 1 had impaired cognition. Further review of the MDS showed Resident 1 was fully dependent on staff for her bladder needs. Resident 1 was always incontinent of bladder. On 12/2/23 at 1518 hours, an interview was conducted with the CNO and the Quality Director. The above findings were verified with the CNO and the Quality Director. 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: 555730 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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)