Pelican Ridge Post Acute

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and medical record review, the facility failed to ensure the baseline care plan was developed to reflect the specific care needs for one of 18 sampled residents (Resident 10). * The facility failed to ensure

a baseline care plan problem was developed to address Resident 10's surgical incision care upon admission to the facility. Resident 10 was admitted to the facility on [DATE REDACTED], however, the facility had not assess, monitor and/or provide wound care to Resident 10's surgical incision until 9/2/25. This failure resulted in the resident's care needs not being met and had the potential to affect the resident's well-being.Findings: Medical record review for Resident 10 was initiated on 9/23/25. Resident 10 was admitted to the facility on [DATE REDACTED], with a surgical wound on the left lateral thoracic (chest) region with three sutures. Review of Resident 10's Skilled Nursing Facility Transfer Orders (from the acute care hospital) dated 4/17/25, showed Resident 10 had an incision site on the left upper lateral chest with the dressing in place. In addition, under the Wound/Skin Care section showed to follow the current recommendations of the wound team for the treatment and follow the standard nursing protocols for the wound care. Review of Resident 10's Baseline Care Plan failed to show a baseline care plan problem was developed to address Resident 10's surgical wound and the provision of required care for the surgical wound with sutures. On 9/25/25 at 1130 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified Resident 10 was admitted to the facility with a surgical wound on the left lateral thoracic region with three sutures. The DON verified a baseline care plan problem was not developed within 48 hours of the resident's admission to the facility, to address Resident 10's surgical wound with sutures. On 9/26/25 at 1652 hours, a telephone interview was conducted with the Administrator and DON. The Administrator and DON verified was informed and verified the above findings. Cross reference F-F684.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0656 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and medical record review, the facility failed to develop and implement a comprehensive person-center care plan for to reflect the individual care needs for one of 18 sampled residents (Resident 10). * The facility failed to ensure a care plan was developed to address Resident 10's refusal of multiple aspects of his plan of care. This failure had the potential to cause inappropriate and inadequate plans of care for the resident.Findings: Medical record review for Resident 10 was initiated on 9/23/25. Resident 10 was admitted to the facility on [DATE REDACTED]. Review of Resident 10's H&P examination dated 4/18/25, showed Resident 10 had the capacity to understand and make decisions. Further Review of resident's medical

record showed Resident 10 was admitted with a surgical wound with sutures, which was not assessed, monitored, accurately documented or cared for until 9/2/25, at which point the wound was assessed and documented accurately, the sutures were removed and the resident began receiving wound care for other unrelated wounds that were discovered on 9/2/25. Review of Resident 10's Inter-Disciplinary Team note dated 9/2/25 at 1445 hours, showed Resident 10 refused ADL care and dialysis. On 9/23/25 at 1355 hours,

an interview was conducted with the Wound Care Nurse. The Wound Care Nurse verified Resident 10 frequently refused all aspects of his plan of care, including skin assessment, dialysis for two weeks, which ultimately required hospitalization, medications and repositioning to prevent pressure injuries. The Wound Care Nurse stated he believed the resident's wound and sutures were not discovered for four and a half months after his admission to the facility due to his refusals of care. Review of Resident 10's Wound Care Note dated 9/24/25, showed Resident 10 had been refusing wound care and dialysis necessitating hospitalization. However, review of Resident 10's plan of care failed to show a care plan problem was developed to address the resident's refusal of multiple aspects of his plan of care, including frequent refusals of dialysis, repositioning, medications and assessment of his skin and wounds. On 9/24/25 at 1130 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no care plan developed to address the resident's refusal of multiple aspects of his plan of care.

The DON stated she believed the surgical wound was missed due to the resident's frequent refusal of skin assessment and care from the facility staff. The DON verified the resident's refusals should have been incorporated into the resident's plan of care. On 9/25/25 at 1000 hours, an observation and concurrent

interview was conducted with the Wound Care Nurse for Resident 10. Resident 10 was observed refusing wound care. The Wound Care Nurse stated Resident 10 had refused his medications and dialysis that morning. On 9/26/25 at 1652 hours, a telephone interview was conducted with the Administrator and DON.

The Administrator and DON were informed and verified the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0657 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 revise the resident centered care plan for one of three sampled residents (Resident 8) reviewed for fall. * The facility failed to revise Resident 8's care plan and reassess the effectiveness of the interventions of Resident 8's care plan when Resident 8 fell on 9/14 and 9/16/25. This failure placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Fall/ Accident Mitigation and Intervention dated October 2024 showed the facility nursing staff and/or the IDT shall update the resident's plan of careaccordingly, to reduce the risk of further occurrences of a fall or other event. Review of the facility's P&P titled General Documentation Guidelines dated 10/2024 showed it is the policy of this facility to document relevant findings in the clinical record specific to each individual resident's needs and condition. Medical record review for Resident 8 was initiated on 9/22/25. Resident 8 was admitted to the facility on [DATE REDACTED]. Review of Resident 8's plan of care showed a care plan problem dated 5/7/25, addressing the resident's risk for fall. Review of Resident 8's plan of care showed a care plan problem revised 9/6/25, addressing the resident's actual fall incidents with no injuries. Review of Resident 8's progress notes showed the following documentation:- on 9/14/25 at 1903 hours, Resident 8 was found

on the floor, next to the bedroom door; and - on 9/16/25 at 1303 hours, Resident 8 sustained two new skin tears due to a fall. However, further review of Resident 8's plan of care failed to show the care plan problem addressing the resident's actual fall incidents was revised and the effectiveness of the interventions was reassessed when Resident fell on 9/14 and 9/16/25. On 9/19/25 at 1452 hours, an interview and concurrent medical record review were conducted with RNs 2 and 3. RNs 2 and 3 verified Resident 8's care plan was not revised when the resident fell on 9/14 and 9/16/25. RN 2 stated the fall care plan must be revised to reflect the current resident status so the facility staff would have a guide for the resident's plan of care. On 9/23/25 at 1000 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified Resident 8's care plan was not revised to address the resident's fall episodes 9/14 and 9/16/25. The DON stated the resident's care plan should have been updated and revised.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

ADL care. On 9/25/25 at 1130 hours, an interview was conducted with the DON. The DON verified the above findings and stated the licensed nurses were required to fully assess the resident's skin on admission to the facility, readmission and weekly, if there were no concerns. The DON verified the direct care staff were required to assess the resident's skin when bathing, changing or repositioning the resident.

The DON verified the discharge instructions from the acute care hospital for Resident 10's wound care dated 4/17/25. The DON verified the facility failed to assess, monitor, and provide care for the resident's surgical incision with sutures, that was present on admission. On 9/26/25 at 1652 hours, a telephone

interview was conducted with the Administrator and DON. The Administrator and DON were informed and verified the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview and concurrent medical record review was conducted with RN 2. RN 2 reviewed Resident 8's medical record and verified the above findings. RN 2 stated it was important to complete the post fall followup documentation to check if there were any changes in the resident's condition. On 9/19/25 at 1452 hours

an interview and concurrent medical record review was conducted with RN 3. RN 3 reviewed Resident 8's medical record and verified the resident's progress note on 9/14/25, regarding the resident's fall did not show full assessment of the resident's change in condition. RN 3 verified there were no neurological assessments, assessments for the skin, pain, and fall risk, and 72-hour post fall monitoring and documentation completed after the resident's fall incidents. In addition, RN 3 verified the physician was not notified of the fall on 9/14/25, and the resident's representative was not notified of the fall incidents on 9/14 and 9/16/25. RN 3 stated the MRD and DON checked and reviewed the documentation for completion and accuracy. On 9/22/25 at 845 hours, an interview and concurrent medical record review was conducted with RN 1 for Resident 8. RN 1 stated Resident 8's unwitnessed falls were related to his behavior of getting up unassisted. However, RN 1 stated the assessments (for the pain, neurocheck, skin and post- fall risk) were still done. RN 1 stated the resident did not exactly have a fall, but the nursing staff monitored Resident 8 for getting up unassisted and the licensed nurses did not complete the follow up notes because they monitored him every day. RN 2 showed the resident's behavior monitoring record, which was incomplete. On 9/22/25 at 950 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated

on 9/16/25, she was told Resident 2 sustained skin tears due to a fall during shift change from the NOC shift to the day shift. LVN 2 stated she checked the resident and documented her findings in the Skin Assessment section of the resident's medical record. LVN 2 further stated she was not aware of the specifics of the fall. LVN 2 verified there was no documentation, including the COC (change of condition), IDT, post fall monitoring, and post fall assessments done addressing the resident's fall on 9/16/25. LVN 2 stated yes, when asked if there should assessments and documentation done to address the fall. On 9/22/24 at 1000 hours, an interview and concurrent medical record review was conducted with the DON.

The DON stated Resident 8's falls were considered a behavior, and an IDT meeting in May 2025 was held to address Resident 8's fall incidents. The DON stated the plan was to monitor Resident 8's behavior of getting up unassisted and record the number of times the behavior was manifested every shift. The DON stated when Resident 8 was found on the floor, it was not considered a fall because it was a behavior. The DON added a fall was when a resident tripped and fell. The DON stated the facility only completed the progress notes and monitoring and if indicated, the neurocheck assessment for unwitnessed incidents. The DON reviewed Resident 8's medical record and verified Resident 8's medical record did not show the COC documentation, IDT notes, the assessments for the neurocheck, pain, skin and post fall, family and physician notification and the post fall monitoring for 72 hours for the resident's fall on 9/14/25 fall. In addition, the DON verified Resident 8's medical record did not show the progress notes, COC documentation, IDT notes, the assessments for the neurocheck, pain, and post fall, family notification and

the post fall monitoring for 72 hours for the resident's fall on 9/16/25. On 9/23/25 at 1507 hours, a follow up

interview was conducted with the DON. When the DON was asked what her professional definition of fall was, the DON stated, anything when the part of the body is touching the ground, it's a fall. When the DON was asked regarding Resident 8's incident of being found on the ground, if the incident was considered a fall, the DON stated yes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0695

Provide safe and appropriate respiratory care 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

observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 17 sampled residents (Residents 4 and 5). * The facility failed to ensure Resident 4's CPAP (Continuous Positive Airway Pressure. It is a treatment that uses a machine to deliver mild air pressure through a mask, which prevents the upper airway from collapsing

during sleep. This is the most common treatment for a condition called obstructive sleep apnea) mask was stored in a sanitary manner. * The facility failed to provide a CPAP machine to Resident 5. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.Findings:

Review of the facility's P&P titled Oxygen Administration revised 11/2021, showed it is the policy of this facility that oxygen therapy be administered upon a physician order or, in the event of an emergency, by a licensed nurse or respiratory therapist. 1. Medical record review for Resident 4 was initiated on 9/19/25.

Resident 4 was admitted to the facility on [DATE REDACTED]. Review of Resident 4's Order Summary Report showed

the following orders: - dated 9/10/25, CPAP use at bedtime for sleep apnea every night shift.- dated 9/10/25, CPAP change or clean intake filter, and disposable supplies per manufacture guidelines or if soiled every evening and night shift. On 9/19/25 at 0940 hours, during an observation, Resident 4's CPAP mask was on the floor, and the bag to place the CPAP mask was not in Resident 4's room. On 9/19/25 at 1005 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 picked Resident 4's CPAP mask off the floor and placed it into a pink basin. LVN 4 verified there was no plastic bag to store the CPAP mask. LVN 4 stated the risk of the CPAP mask being on the floor could be a risk for infection. 2.

Medical record for Resident 5 was initiated on 9/19/25. Resident 5 was admitted to the facility on [DATE REDACTED].

Review of Resident 5's Order Summary Report showed an order dated 9/11/25, for CPAP at bedtime for obstructive sleep apnea (sleep disorder characterized by repeated episodes of partial or complete blockage of the upper airway during sleep). Review of Resident 5's care plan for ineffective breathing pattern related to obstructive sleep apnea dated 9/17/25, showed interventions including to apply at CPAP at bedtime, evaluate lung sounds, evaluate for shortness of breath, and to monitor for periods of apnea while sleeping.

On 9/19/25 at 1022 hours, an observation and concurrent interview was conducted with Resident 5. There was no CPAP machine in Resident 5's room. Resident 5 stated she has not had a CPAP machine since she was admitted to the facility. On 9/19/25 at 1027 hours, an observation, interview and concurrent medical

record review was conducted with RN 2. RN 2 verified Resident 5 had an order for CPAP to be applied every night. RN 2 further verified there was no CPAP at Resident 5's bedside, and Resident 5 was not receiving the CPAP treatment. On 9/19/25 at 1044 hours, an observation, interview and concurrent medical

record review was conducted with the DON. The DON verified the CPAP mask for Resident 4 should not have been on the floor. The DON further verified Resident 5 did not have the CPAP machine and was not receiving the CPAP as ordered by the physician. On 9/26/25 at 1652 hours, the Administrator and the DON acknowledged the above findings.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0698

the building on the above dates, CNA 6 stated I don't remember him leaving the building.

Level of Harm - Minimal harm or potential for actual harm

On 9/25/25 at 0923 hours, an interview was conducted with the Receptionist. The Receptionist verified she worked on 9/5 and 9/8/25. The Receptionist stated she remembered Resident 18 and did not see him waiting in the lobby for his dialysis or any appointment. The Receptionist further stated if Resident 18 was in

the lobby and not picked up, she would call the CNA or the licensed nurse.

Residents Affected - Few

On 9/25/25 at 1214 hours, an interview and concurrent medical record review were conducted with LVN 5.

LVN 5 stated she worked on 9/8/25, and did not physically see Resident 18 leave the building. LVN 5 further stated she did not see Resident 18 on his wheelchair arriving to the facility from an appointment and only saw him lying on bed in his room. When LVN 5 was asked if she was sure Resident 18 went to dialysis on 9/8/25, LVN 5 responded I am not 100 % sure, it's a blur. I did not see him coming in. I should have asked

the resident, asked the CNA and called the front desk, if he had dialysis.

1. 2. Medical record review for Resident 10 was initiated on 9/23/25. Resident 10 was admitted to the facility

on [DATE REDACTED]. Resident 10 had a diagnosis of end-stage renal disease (condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products and excess fluid from the blood) and had a Perma-Cath (a type of in-dwelling catheter that allows for the performance of hemodialysis) on in his left thigh.

Review of Resident 10's Dialysis Communication dated 9/2/25, showed Resident 10's vascular access device was incorrectly specified as a Port- A-Cath.

Review of Resident 10's Order Summary Report dated 9/23/25, showed a physician's order dated 9/21/25, for Resident 10's dialysis access site monitoring, which was specified as a Port-A-Cath (an indwelling vascular access that is typically implanted in the chest wall and used for long term vascular access to administer intravenous medications such as chemotherapy, transfusions or intravenous nutrition).

On 9/25/25 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 10's physician's order incorrectly specified the resident's Perma-Cath dialysis access site as a Port-A-Cath. The DON verified Resident 10's dialysis access was a Perma-Cath.

On 9/26/25 at 1652 hours, a telephone interview was conducted with the Administrator and DON. The Administrator and DON were informed and verified the above findings.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and facility document review, the facility failed to ensure the licensed nurses and certified nursing assistants (CNA) had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents as evidenced by: * Resident 10 was admitted on [DATE REDACTED], with a surgical incision with three sutures that was not assessed, monitored or had care provided from the date of admission until 9/2/25, when the wound was brought to the attention of the facility by the resident's outpatient dialysis clinic. This failure had the potential to put the Resident 10 at risk for care not provided in a safe and competent manner. Findings: Medical record review for Resident 10 was initiated on 9/23/25. Resident 10 was admitted to the facility on [DATE REDACTED]. Resident 10 had left pleural effusion (a buildup of fluid in the space around the lung) and left chest tube placement (a tube placed into the space around

the lung to drain the accumulated fluid) in the acute care hospital, which was removed on 4/16/25. Review of Resident 10's H&P examination dated 4/18/25, showed Resident 10 had the capacity to understand and make decisions. Review of Resident 10's Skilled Nursing Facility Transfer Orders (from the acute care hospital) dated 4/17/25, showed Resident 10 had an incision site on the left upper lateral chest with the dressing in place. In addition, under the Wound/Skin Care section showed to follow current recommendations of the wound team for treatment and follow standard nursing protocols for wound care.

Review of Resident 10's admission Skin assessment dated [DATE REDACTED], showed the resident had a surgical incision with an intact dressing on left rear flank and present on admission. However, further review of Resident 10's medical record showed the wound was not assessed by the facility staff until 9/2/25, at which time the wound was assessed and the sutures were removed. Resident 10 required maximum assistance with all his ADL care and therefore received care from multiple licensed nurses and CNAs per each shift in

the facility. Resident 10's surgical wound was in an easily visible location on his left lateral flank and was documented on weekly progress notes as present, covered by an intact dressing and not evaluated until 9/2/25. On 9/25/25 at 1110 hours, an interview and concurrent facility document review was conducted with

the DSD. The DSD verified the facility's skills competencies check off for the CNAs and licensed nurses did not include the skin assessment. The DSD verified the skin assessment was a required competency for the CNAs and licensed nurses. The DSD verified multiple direct care staff per each shift from the date of admission until 9/2/25, missed to assess and accurately document the resident's surgical wound. The DSD stated the resident's surgical wound was missed by multiple licensed nurses and CNAs because they were not performing the skin assessments as they were required to do. On 9/25/25 at 1130 hours, an interview and concurrent facility document review was conducted with DON. The DON verified the facility's skills competencies for the CNAs and licensed nurses did not include the skin assessment. The DON verified the skin assessment was a required competency for the CNAs and licensed nurses. The DSD verified multiple direct care staff per each shift from the date of admission until 9/2/25, missed to assess and accurately document the resident's surgical wound. The DON stated the resident's surgical wound was missed by multiple licensed nurses and CNAs because they were not performing the skin assessments as they were required to do. On 9/26/25 at 1652 hours, a telephone interview was conducted with the Administrator and DON. The Administrator and DON were informed and verified the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm

lidocaine patch, the new process was to perform count sheets since the documentation showed Resident 11 received his patch but was not applied. On 9/26/25 at 1540 hours, an interview with Pharmacy 1 was conducted. Pharmacy 1 verified the facility received 10 Asperflex 4% patches and 14 Lidocaine 5% patches

on 8/15/25 for Resident 11. Pharmacy 1 verified there were no other deliveries for the patches. On 9/26/25 at 1652 hours, the Administrator and the DON acknowledged the above findings. Cross reference to F-F842.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0842 Level of Harm - Potential for minimal harm Residents Affected - Some

Medical record review for Resident 11 was initiated on 9/3/25. Resident 11 was readmitted to the facility on [DATE REDACTED].

Review of Resident 11's Order Summary Report showed the following orders: - dated 8/17/25, Asperflex Lidocaine (pain relieving patch) 4.0% patch to be applied to lower back topically one time a day for pain management and remove per schedule - dated 8/15/25, Lidoderm patch 5% (Lidocaine) (pain relieving patch) apply to right hip one time a day for pain management for 30 days.

Review of Resident 11's MAR for September 2025 showed the following dates and times: - on 9/1/25 at 0900 hours, Asperflex Lidocaine 4.0% patch applied to lower back - on 9/1/25 at 0900 hours, Lidoderm patch 5% patch applied to right hip - on 9/1/25 at 2100 hours, Asperflex Lidocaine 4.0% patch, lower back patch was removed - on 9/1/25 at 2100 hours, Lidoderm patch 5% patch on right hip was removed - on 9/2/25 at 0900 hours, Asperflex Lidocaine 4.0% patch applied to lower back - on 9/2/25 at 0900 hours, Lidoderm patch 5% patch applied to right hip - on 9/2/25 at 2100 hours, Asperflex Lidocaine 4.0% patch, lower back patch was removed - on 9/3/25 at 0900 hours, Lidoderm patch 5% patch applied to right hip - on 9/3/25 at 0900 hours, Asperflex Lidocaine 4.0% patch applied to lower back - on 9/2/25 at 2100 hours, Lidoderm patch 5% patch on right hip was removed

On 9/3/25 at 1509 hours, an observation and concurrent interview was conducted with Resident 11.

Resident 11 asked a licensed nurse for his lidocaine patch. The licensed nurse left and did not return.

Resident 11 stated he did not receive his lidocaine patches on 9/2 and 9/3/25.

On 9/3/25 at 1701 hours, an observation, interview and concurrent medical record review was conducted with the DON. The DON verified the lidocaine patch for Resident 11 was not applied, and was documented

it had been applied on 9/2 and 9/3/25 on Resident 11's MAR.

On 9/26/25 at 1652 hours, the Administrator and the DON acknowledged the above findings.

Cross reference to F-F755

FORM CMS-2567 (02/99) Previous Versions Obsolete

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