Pelican Ridge Post Acute

F 0552

Ensure that residents are fully informed and understand their health status, care and treatments.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and medical record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was informed of the risks and benefits of proposed care, treatment, and treatment alternatives or options, and the choice to choose an alternative option in advance. * The facility failed to ensure Resident 2 and Family Member 1 were informed of the risks and benefits of using the IV fluid therapy, as well as providing alternative options for treatment. This failure had the potential for Resident 2 and Family Member 1 to not to be informed of the IV fluid solution and its potential effects, and prevent the resident from participating in choosing her treatment decisions.Findings: Medical record review for Resident 2 was initiated on 9/30/25.

Resident 2 was admitted to the facility on [DATE REDACTED]. Review of Resident 2's MDS five-day assessment dated [DATE REDACTED], showed Resident 2's BIMS Summary Score was 6, indicating severe cognitive impairment. Review of Resident 2's Order Summary Report showed the following orders:- dated 9/15/25, to administer Dextrose Intravenous Solution 5% (a sterile mixture of dextrose, a form of glucose, and water given directly into a patient's vein) use 1000 ml intravenously.- dated 9/16/25, to administer Dextrose Intravenous Solution 5% with multivitamin use 1000 ml bag to infuse 60 ml per hour ml/hr to provide 2 L. Review of Resident 2's IV Administration Report for September 2025 showed Resident 2 received the Dextrose Intravenous Solution 5% use 1000 ml intravenously on 9/15/25 at 2003 hours. Further review of Resident 2's medical record failed to show Family Member 1 was informed of the physician's order for Dextrose Intravenous Solution 5% intravenously, its potential effects and was provided the option to choose for alternative options. On 9/30/25 at 1640 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated the IV fluids were given to Resident 2 without her knowledge. Family Member 1 stated she was not informed of

the IV fluid therapy and was afraid the IV therapy posed a dangerous risk for the resident. Family Member 1 further stated she saw the IV fluids infusing when she visited the resident. On 10/1/25 at 1035 hours, an

interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 2 was given the Dextrose Intravenous Solution 5% on 9/15/25. RN 1 stated she was not sure why the resident was started on IV therapy. RN 1 verified Resident 2's medical record failed to show documented evidence of the indication for Dextrose Intravenous Solution 5% ordered by the physician, notification regarding the use of IV fluids to Family Member 1. On 10/3/25 at 1615 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

Residents Affected - Few

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

10/06/2025

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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

recommendations including a social services consult with the resident. Review of Resident 10's MAR for August 2025 showed on 8/30/25, there were seven episodes of physical aggression toward staff between 1900 hours to 0700 hours. Review of Resident 10's medical record failed to show documented evidence of

a change in condition, progress notes, or family and MD notification for the incident on 8/29/25. Review of Resident 10's Change of Condition dated 9/27/25, showed Resident 10 hit another resident on the right hand. On 10/3/25 at 0952 hours, an interview was conducted with CNA 6. CNA 6 stated they questioned Resident 10 of the incident of hitting Resident 9 on the hand, however Resident 10 refused to answer. CNA 6 stated Resident 10 had a history of aggressive behavior and had an incident not too long ago. CNA 6 stated the previous incident occurred where Resident 10 hit another resident. On 10/3025 at 1025 hours,

an interview was conducted with CNA 7. CNA 7 stated Resident 10 gets agitated where they yell and curse.

CNA 7 also stated Resident 10 gets agitated to the point where they feel Resident 10 would hit them. On 10/3/25 at 1104 hours, a telephone interview was conducted with LVN 9. LVN 9 stated Resident 10 had a history of aggression and has hit another resident in the past. LVN 9 also confirmed after an abuse incident, monitoring and documenting should be for 72 hours on every shift. On 10/3/25 at 1416 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated a witness saw Resident 10 hitting Resident 9. The DON verified Resident 10 had a history of aggression and had a similar incident in the past month. The DON confirmed monitoring following an incident should be for 72 hours on every shift. The DON verified Resident 9 was not monitored for 72 hours. On 10/6/25 at 1011 hours, an

interview was conducted with Social Services 2. Social Services 2 verified an IDT care conference meeting occurred on 8/29/25, with the recommendation for Resident 10 to have a social services consultation.

Social Services 2 could not find documentation Resident 10 received a social services consultation. On 10/6/25 at 1313 hours, an interview was conducted with LVN 8. LVN 8 verified documentation of Resident 10's monitoring of physical aggression toward staff between 1900 hours to 0700 hours showed seven episodes on 8/30/25. LVN 8 stated a progress note of the behavior's should have been documented. LVN 8 also stated a change of condition should have been documented, along with notifying family and MD. On 10/6/25 at 1336 hours, an interview was conducted with RN 2. RN 2 stated the MD should have been notified regarding Resident 10 with seven episodes of aggression towards the staff on 8/30/25, to escalate psychiatry care. On 10/6/25 at 1520 hours, the DON and Administrator were made aware of 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

10/06/2025

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-centered care plan to reflect the individual care needs for one of 12 sampled residents (Resident 2). * The facility failed to ensure a care plan was developed to address Resident 2's use of IV fluids. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.Findings: Medical record review for Resident 2 was initiated on 9/30/25. Resident 2 was admitted to the facility on [DATE REDACTED]. Review of Resident 2's MDS five-day assessment dated [DATE REDACTED], showed Resident 2's BIMS Summary Score was 6, indicating severe cognitive impairment. Review of Resident 2's Order Summary Report showed the following orders:- dated 9/15/25, to administer Dextrose Intravenous Solution 5% (a sterile mixture of dextrose, a form of glucose, and water given directly into a patient's vein) use 1000 ml intravenously.- dated 9/16/25, to administer Dextrose Intravenous Solution 5% with multivitamin use 1000 ml bag to infuse 60 ml per hour ml/hr to provide 2 L. Review of Resident 2's IV Administration Report for September 2025 showed Resident 2 received the Dextrose Intravenous Solution 5% use 1000 ml intravenously on 9/15/25 at 2003 hours. Further review of Resident 2's medical record failed to show a plan of care was developed for the use of intravenous therapy. On 10/1/25 at 1035 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified Resident 2 was given the Dextrose Intravenous Solution 5% on 9/15/25. RN 1 verified Resident 2's medical record failed to show a plan of care was developed for the resident's use of Dextrose Intravenous Solution 5%. On 10/3/25 at 1615 hours, an interview was conducted with the DON. The DON was informed and acknowledged 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

10/06/2025

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

stated the resident should have been observed for 72 hours, and the resident's condition should have been documented in the nurses progress notes. On 10/3/25 at 0735 hours, an interview was conducted with LVN

1. 3. LVN 3 stated Resident 2 told him she leaned over and bumped her head over the bedside table. LVN 3

stated the resident should have been monitored for follow up care for her injury of having the lump on the head with slight swelling. LVN 3 stated he was not sure if he wrote Resident 2's name in the communication sheet for monitoring of the change of condition. On 10/3/25 at 1615 hours, an interview was conducted with

the DON. The DON stated the licensed nurses should have documented resident's condition in the nurses progress notes. The DON was informed and acknowledged 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

10/06/2025

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 0849 Level of Harm - Potential for minimal harm Residents Affected - Some

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

facility nurse's name who she checked in when she visited and she stated she did not get the facility nurse's name, however, she knows their faces. The Hospice Case Manager stated since she did not get the facility nurses' names whenever she visited Resident 8, she did not document which facility nurses she checked in and received updates. The Hospice Case Manager stated another case manager visited Resident 8 on 10/3/25, however, verified there was no documented evidence in Residents 8's hospice binder of the mentioned visit. The Hospice Case Manager stated it was part of their training (hospice provider) for the skilled nurses to sign in and document in the hospice staff communication note located in Resident 8's hospice binder after each visit. Furthermore, the Hospice Case Manager stated if it was not documented, it was not completed. On 10/6/25 at 1320 hours, an interview was conducted with the Hospice Patient Care Manager. The Hospice Patient Care Manager stated all hospice disciplines including the skilled nurses, hospice aides, social workers, chaplains and physicians must sign in the hospice binder and facility to track who provided the care, which would show compliance with plan of care, coordination, and communication with the facility. The Hospice Patient Care Manager stated there was a sign-in sheet and staff communication notes in each of the hospice residents' binder, which must be filled out after each hospice discipline visit. The Hospice Patient Care Manager stated all the hospice disciplines were informed and oriented they must sign in the hospice binder with every visit. Furthermore, the Hospice Patient Care Manager stated the Hospice Case Managers were responsible for checking the hospice binder of the residents to make sure all involved disciplines including the Hospice Aide had completed their scheduled visits every week. The Hospice Patient Care Manager stated he was not aware of the missing visits and hospice staff not signing in for Resident 8. On 10/7/25 at 1411 hours, an interview and concurrent medical

record review for Resident 8 was conducted with the DON. The DON stated there was a hospice book for each of the hospice resident and she expected all the hospice disciplines to sign in every visit. The DON stated the charge nurses assigned to the hospice residents must document when the hospice nurses and hospice aides visited. The DON stated the RN and LVNs assigned to the hospice residents were responsible for checking if each hospice resident had received the scheduled visits from the hospice disciplines, which must be documented in each of the resident's hospice binder under the sign in sheet and/or staff communication note. In addition, the DON stated it was important for each hospice discipline to sign in the hospice binder to show hospice services were provided to the hospice residents. The DON stated if the charge nurses have checked the hospice binder and noted missing hospice visits, they should inform the social services staff, who would follow up with the hospice company during the care conference.

Furthermore, the DON stated with hospice services not coming in the facility for hospice residents would not have made any difference, however, the 1:1 support from hospice care would be missing. On 10/7/25 at 1540 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet