Health inspection·February 18, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of three sampled residents (Resident 2). This failure had the potential for the resident's care needs not being met as the medical information was inaccurate. Findings: Review of the facility's P&P titled Medication Orders – effective date April 2008 showed the following steps are initiated to complete documentation and receive the medications: a. Clarify the order as necessary. b. Enter the orders on a medication order form. c. Call, fax, or electronically transfer the medication order to the provider pharmacy. d. Transcribe newly prescribed medications on the MAR or TAR. When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by writing DC'd and the date. Enter the new order on the MAR/TAR. Review of the facility's P&P titled Medication Administration – General Guidelines effective October 2017 showed the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. Medical record review for Resident 2 was initiated on 2/12/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report for February 2025, showed an ordered dated 1/30/25, for Jevity 1.5 (enteral feeding formula) at 50 ml per hour until [NAME] Farms 1.4 arrived and to hold for loose stool. Review of Resident 1's MARs for January and February 2025 showed the [NAME] Farms 1.4 enteral feeding formula was scheduled to be administered every shift continuously at 60 ml per hour. The feedings were signed as administered from 1/30/21 at 1900 hours to 2/10/25. However, there was no input order for the Jevity 1.5 enteral feeding. (continued on next page) 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: 055121 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 055121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2025 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)