Pelican Ridge Post Acute: Missing Medication Patches - CA
Federal inspectors cited the facility following a complaint inspection completed September 25, 2025, documenting that Resident 11 had been prescribed both Asperflex 4% patches and Lidocaine 5% patches, medications used to manage pain. The pharmacy confirmed it had delivered 10 Asperflex patches and 14 Lidocaine patches to the facility on August 15. No other deliveries for those medications were made. Yet when inspectors examined the documentation, something didn't line up: the records showed Resident 11 had received his patch, but it had not been applied.
The gap between what was charted and what actually happened is the central problem inspectors identified. A nurse documenting a medication as administered when it was not administered is not a paperwork technicality. For a patient relying on a lidocaine patch for pain control, the difference between "documented as given" and "actually on the body" is the difference between managed pain and unmanaged pain.
How many patches went unaccounted for isn't spelled out in the inspection report. What is spelled out is that the pharmacy delivered a specific quantity, no additional deliveries occurred, and the documentation showed at least one instance where a patch was recorded as received but not applied. The facility, after the problem was identified, moved to implement count sheets for the lidocaine patches, a process meant to track where each patch goes from delivery to application.
That the count sheet process was described as "new" at the time of the inspection means it wasn't in place before. The patches were being delivered, logged, and somewhere between the medication cart and the resident's skin, the accounting broke down.
On September 26, the day after the inspection concluded, an investigator spoke with the facility's pharmacy contact. The pharmacist confirmed the delivery numbers: 10 Asperflex patches, 14 Lidocaine patches, all on August 15, all for Resident 11. No other shipments. That same afternoon, at 4:52 p.m., the facility's Administrator and Director of Nursing sat down with the inspector and acknowledged what had been found.
Acknowledging findings is not the same as explaining them. The inspection report does not record any explanation from the Administrator or the Director of Nursing for how the documentation came to reflect a patch application that didn't happen, or for how long the discrepancy had existed before inspectors arrived.
The deficiency was cited under F0755, which covers pharmacy services and medication management, and was tagged at a level of minimal harm or potential for actual harm. Inspectors noted that few residents were affected. The citation cross-references F842, which relates to medical records, a pairing that underscores what inspectors found: not just a medication that wasn't given, but a record that said it was.
Pelican Ridge Post Acute operates at 466 Flagship Road in Newport Beach. The inspection was triggered by a complaint.
For Resident 11, the practical question is a simple one. He was prescribed pain patches. The pharmacy sent them. The records said he got them. Whether the medication was actually controlling his pain during the weeks between that August delivery and the September inspection is something the inspection report doesn't answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Ridge Post Acute from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 2026 · Our methodology
PELICAN RIDGE POST ACUTE in NEWPORT BEACH, CA was cited for violations during a health inspection on September 25, 2025.
The pharmacy confirmed it had delivered 10 Asperflex patches and 14 Lidocaine patches to the facility on August 15.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.