Health inspection·July 9, 2025

F 0557 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and medical record review, the facility failed to ensure one of eight sampled residents (Resident 1) was treated with dignity and respect when the facility failed to send some of Resident 1's belongings upon discharge from the facility. This failure had the potential to negatively affect Resident 1's well-being.Findings: Closed medical record review for Resident 1 was initiated on 7/7/25. Resident 1 was admitted to the facility on [DATE], and was discharged to home on 5/24/25. Review of the facility's document titled Resident's Clothing and Possessions dated and signed by Resident 1 and the facility staff on 5/13/25, showed Resident 1 had one black shoes, one black pair of socks, three t-shirts, one pant, one green walker, one wallet with ID, one Samsung cell phone, one black jacket, and $175 cash upon admission to the facility. Review of Resident 1's H&P examination dated 5/14/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS score of 15, which meant the resident was cognitively intact. Review of the facility's document titled Resident's Clothing and Possessions dated and signed by Resident 1 and the facility staff on 5/24/25, showed Resident 1 was sent with the following items upon discharge: one pair of glasses, one wallet with ID, one black belt, one black cell phone, two black pairs of shoes, and one green walker. On 7/8/25 at 1530 hours, an interview was conducted with the SSA. When asked about the facility's process regarding resident's missing clothing, the SSA stated the staff were notified, logged in the facility's Theft and Loss, looked for the items in the areas throughout the facility, checked the inventory list, if not in the inventory list, the family was notified. When asked if the facility was aware of any missing belongings for Resident 1, the SSA stated no, not that she could remember. On 7/9/25 at 0958 hours, a telephone interview was conducted with Resident 1. Resident 1 stated he had the following missing clothes from the facility: three shirts (one blue, one white, and one house shirt-spandex material), one black jacket, one pair of blue jeans. Resident 1 also stated he was missing money, however, could not remember if it was $500 or more. In addition, Resident 1 stated he had called the facility with no return call received. On 7/9/25 at 0959 hours, an interview was conducted with the Housekeeping Director. When asked about her role when the residents who were discharged from the facility left behind personal clothes or belongings in the facility, the Housekeeping Director stated she checked her office if the personal belongings of the residents were stored for the discharged residents and then followed up with the Social Services staff who would call the discharged residents. The Housekeeping Director was asked to check in her office if Resident 1 had personal clothes left behind in the facility upon discharge. On 7/9/25 at 1024 hours, an observation of Resident 1's belongings and concurrent interview was conducted with the Housekeeping Director. The Housekeeping Director showed a box with Resident 1's clothes which included three shirts (one white shirt, one blue shirt and one gray shirt), one black jacket, and one pair of blue jeans. The Housekeeping Director (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 3 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 07/09/2025 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)