Pelican Ridge Post Acute

F-F600.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 055121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055121 B. Wing 04/18/2025

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)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49348 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Few the facility failed to implement the systematic approach to ensure the effective monitoring of the acceptable parameters of nutrition status for two sampled residents (Residents3 and 4).

* The facility failed to ensure Resident 3 was assessed and monitored by the IDT when Resident 3 had a severe weight loss of 51 lbs. (-23.29%) in the last six months, 14 lbs. (6.39%) in one month from 9/12 - 10/16/24, and 30 lbs. (14%) from 1/3 - 2/16/25. In addition, the facility failed to initiate a COC for Resident 3 when there was a severe weight loss, including notifying the physician, and legal representative.

* The facility failed to ensure Resident 4 was assessed and monitored by the IDT when Resident 4 had a severe weight loss of 17 lbs. (12.14%) in one month. In addition, the facility failed to initiate a COC for Resident 4 when there was a severe weight loss, including notifying the physician and legal representative, ensure the resident centered plan of care reflected the goals or interventions regarding the risk for weight loss, and monitor the weekly weights as ordered by the physician.

These failures posed the risk of nutritional interventions not being implemented in a timely manner and cause

the residents to have further weight loss.

Findings:

1. Closed medical record review for Resident 3 was initiated on 4/17/25. Resident 3 was admitted to the facility on [DATE REDACTED], and transferred to the acute care facility on 4/16/25. Resident 3 had diagnoses including enterocolitis due to clostridium difficile, anemia, and gastro-esophageal reflux disease.

Review of Resident 3's Order Summary Report showed the following physician'sorder:

- dated 3/7/25, to add snacks at 1400 and 200 hours to supplement meal intake;

- dated 3/29/25, for oral nutrition supplement two times a day for supplement; and

- dated 3/13/25, to obtain weights for 3 weeks one time a day every seven days for 21 days.

Review of Resident 3's Care Plan Report dated 2/17/25, showed a care plan problem addressing the resident is at risk for weight loss, nutrition, hydration, skin integrity complication related to his current health, therapeutic diet and history of c-diff episodes. The interventions included the IDT will assist resident during meals, will encourage the resident to consume adequate and appropriate nutrition as recommended, will monitor the resident for nutrition intake and weights per protocol.

Review of Resident 3's Weights and Vitals Summary showed the following resident's weights:

- dated 9/12/24, 219 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 055121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055121 B. Wing 04/18/2025

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)

F 0692 - dated 10/16/24, 205 lbs., a weight loss of 14 lbs. (6.39%)

Level of Harm - Minimal harm or - dated 1/3/25, 206 lbs. potential for actual harm - dated 2/16/25, 173 lbs., a weight loss of-3 lbs. (16.02%) Residents Affected - Few

Review of Resident 3's eINTERACT Change in Condition Evaluation V5.1 dated 11/14/24, showed Resident 3 had a 9.1% weight loss in the past month. The provider notification and feedback indicated for an RD consult.

However, further review of Resident 3's medical record showed the RD nutritional assessment was not done until 12/3/24.

Review of Resident 3's Interdisciplinary Care Conference V5 dated 3/12/25, showed a weight variance of -32 lbs., 24 days after Resident 3 had lost 33 lbs. from 1/3/25 to 2/16/25.

Further review of Resident 3's medical record did not show a COC was initiated when Resident 3 had severe weight loss of 14 lbs. from 9/12 -10/16/24, and 33 lbs. from 1/3-2/16/25, including the notification of Resident 3's physician and legal representative.

2. Medical record review for Resident 4 was initiated on 4/17/25. Resident 4 was admitted to the facility on [DATE REDACTED]. Resident 4 had a diagnosis of dysphagia oropharyngeal phase.

Review of Resident 4's Care Plan Report dated 3/18/25, showed a care plan problem to address the resident's risk of weight loss. The interventions included to add multivitamin/minerals (supplement) daily, Prostat (protein supplement beverage) 30 ml daily for 30 days, and weekly weights for three weeks due to a significant weight loss.

Review of Resident 4's Weights and Vital Summary showed the following resident's weights:

- dated 2/3/25, 140 lbs.

- dated 3/6/25, 123 lbs., a weight loss of 17 lbs. (12.14%)

- dated 3/14/25, 122 lbs.

- dated 4/1/25, 126 lbs.

Review of Resident 4's Interdisciplinary Care Conference dated 3/12/25, showed Resident 4 had a weight variance of -17 lbs. (12.1%) weight loss in one month. The interventions included Prostat, multivitamins, and monitor weight for three weeks.

Further review of the Weights and Vital Summary did not show Resident 4's weights were monitored after 3/14/24 until 4/1/25 (14 days) later.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 055121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055121 B. Wing 04/18/2025

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)

F 0692 On 4/17/25 at 1320 hours, an interview was conducted with Resident 4. Resident 4 stated he was notified he was losing weight but was not aware how much weight he had lost. Resident 4 stated he used to be 140-150 Level of Harm - Minimal harm or lbs. In addition, Resident 4 stated there was no discussion on how much weight he hadlost, and what the potential for actual harm facility was implementing regarding the weight loss. Resident 4 stated he would like to gain his weight back.

Residents Affected - Few On 4/18/25 at 1538 hours, an interview was conducted with RD 1. The RD 1 stated the significant weight loss was greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months. RD 1 stated when there was a significant weight change, the process would include to notify the DON, and the LVN would initiate a COC. RD 1 verified she did not notify the physician for Resident 3's severe weight loss of 51 lbs. (23.29%) in the last six months.

On 4/18/25 at 1606 hours, an interview was conducted with the DON. The DON verified when there was a significant weight change of five % or more, the staff should initiate a change of condition, which included for monitoring the resident, physician's notification, the legal representative notification, an RD consult, and IDT evaluation should be done. The DON stated once the weight was entered into the medical records, the COC should be done immediately. The DON verified the above findings.

On 4/18/25 at 1639 hours, the Administrator and DON was made aware and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 055121