Health inspection·September 25, 2025

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]. 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: 055121 If continuation sheet Page 2 of 15 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 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]. 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: 055121 If continuation sheet Page 3 of 15 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 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and the facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of 18 sampled residents (Resident 10). * Resident 10 was admitted to the facility from the acute care hospital on 4/17/25, with a surgical incision with three stitches on his left lateral thoracic region. The facility failed to assess and monitor the surgical wound, note the presence of the stitches and provide wound care since the resident's admission to the facility until the wound was brought to the facility's attention on 9/2/25, by the resident's outpatient dialysis clinic. This failure resulted in a delay in identifying the resident's surgical incision and providing the care required, which had the potential to place the resident at harm for impaired healing and increased risk for infection.Findings: Medical record review for Resident 10 was initiated on 9/23/25. Resident 10 was admitted to the facility on [DATE]. 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], showed the resident had a surgical incision with an intact dressing on left rear flank and present on admission. Review of Resident 10's progress notes for the Long Term Care Evaluation from 4/17 until 9/2/25, showed under the Skin Issue #001 section, the resident had a surgical incision on the left rear flank (side of the abdomen, extending from the lower ribs to the hips) with an intact dressing that was present on admission. In addition, the progress note showed Skin issue has not been evaluated regarding the resident's surgical incision. Review of Resident 10's Baseline Care Plan dated 4/17/25, 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. Review of Resident 10's progress notes dated 9/2/25, showed documentation the Wound Care Nurse assessed the presence of a healed surgical incision on Resident 10's left rear flank with three sutures. The three sutures were removed upon the assessment on 9/2/25. On 9/22/25 at 1355 hours, an interview was conducted with the Wound Care Nurse. The Wound Care Nurse stated Resident 10 returned from the dialysis clinic on 9/2/25, and the dialysis clinic had informed the facility Resident 10 had a healed surgical incision on his left lateral flank with sutures present. The Wound Care Nurse then assessed the healed surgical incision and removed the three sutures at the time of the assessment. The Wound Care Nurse verified the surgical incision was fully healed and appeared to be at least several months old. On 9/22/25 at 1330 hours, an interview was conducted with Resident 10. Resident 10 stated the sutures had been in place for a long time before they were removed. Resident 10 stated prior to the removal of the sutures, he had told someone at the facility that the sutures had been in place for a long time. Resident 10 was unable to recall who he had spoken to regarding the sutures. On 9/22/25 at 1330 hours, an interview was conducted with Physician 1, who provided wound care for the resident for an unrelated issue in the same region of the body as the surgical incision. Physician 1 stated the surgical incision on the resident's left lateral flank was in a location that would be easily visible to anyone providing care, such as bathing or cleaning, since the resident who required maximum assistance for his Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055121 If continuation sheet Page 4 of 15 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 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: 055121 If continuation sheet Page 5 of 15 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 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 8) reviewed for fall. * The facility failed to provide the necessary care and services for Resident 8 who had a fall on 9/14 and 9/16/25, including the assessment of the resident's change in condition, neurological assessments and post fall assessments after the falls. In addition, the facility failed to notify the physician and the resident's representative of the fall incidents. This failure had the potential to delay the identification and treatment of a possible fall-related injury and posed the risk of additional falls and injury to the resident.Findings: Review of the facility's P&P titled Fall/Accident Mitigation and Intervention dated October 2024 showed the following: - After a fall or other similar accident or occurrence, the resident shall have a physical assessment documented in the nursing notes in accordance with the facility documentation policy. The attending physician and legal representative or interested family member (if any) shall be notified of the event.- The facility shall begin 72-hour charting after the fall or related accident and continue to assess for latent injuries or changes in condition in accordance with the policy.- After proper assessment of the resident, and the resident is stable, notify the physician and resident representative (if there is one). Once the resident is stable, the facility staff member in charge will complete a report and forward to management as per the facility policy.- The facility nursing staff and/or the IDT shall update the resident's plan of care accordingly, to reduce the risk of further occurrences of a fall or other event. Review of the facility's P&P on Neurological assessment dated [DATE] showed it is the policy of this facility to provide neurological assessments as indicated for the resident involved in an incident or with a condition that may warrant assessment of his/her neurological status. This may include, or not be limited to an unwitnessed fall, resident found on floor, or if there is an incident where the resident has hit his or her head. Neurological Checks are completed within the time frames noted on the Neuro Check Flow Sheet or as ordered by the physician. Review of the facility's in-services provided by the DSD titled Fall Prevention/ Falls given to the facility staff on 5/5, 7/31, 8/11, 8/26, and 9/15/25, showed a fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported or presumed when a resident is on the floor or the ground and can occur anywhere. Review of Resident 8's medical record was initiated on 9/19/25. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's progress note dated 9/14/25 at 1903 hours, showed the resident was found on floor next to the bedroom door. Resident 8 reported no pain or discomfort and was able to make needs known verbally with the vital signs within parameters. Further review of Resident 8's progress notes showed a Skin Issues Note with an effective date of 9/16/25 at 1303 hours, regarding the resident's s/p (status post) fall and with two new skin tears due to the fall. Further review of Resident 8's medical record failed to show the following:- the assessment and documentation of the resident's change in condition, addressing the resident's fall incidents on 9/14 and 9/16/25; - the neurological assessment documentations after the falls on 9/14 and 9/16/25; - the 72 hour post fall monitoring and documentation after the falls on 9/14 and 9/16/25;- the pain assessment after the resident's fall on 9/16/25;- the skin assessment after the resident's fall on 9/14/25;- the IDT assessment and review after the resident's falls on 9/14 and 9/16/25;- the physician notification regarding the resident's fall on 9/14/25; and- the resident's representative notification regarding the resident's fall on 9/14 and 9/16/25. On 9/19/25 at 1433 hours, an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055121 If continuation sheet Page 6 of 15 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 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: 055121 If continuation sheet Page 7 of 15 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 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]. 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]. 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: 055121 If continuation sheet Page 8 of 15 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 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 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 ensure the dialysis care was provided for two of four sampled residents (Residents 10 and18) reviewed for dialysis. * The facility failed to ensure Resident 10's dialysis access was assessed accurately as ordered by the physician. * The facility failed to ensure Resident 18 received the dialysis treatment in an outpatient dialysis center as ordered by the physician. These failures had the potential for the residents not being provided with the appropriate care and treatment, and the possibility of medical complications related to dialysis.Findings: Residents Affected - Few 1. Review of the facility's P&P titled Care of Dialysis Resident dated October 2024 showed it is the policy of the facility to provide nursing care to the dialysis resident in accordance with the physician orders. Review of Resident 18's medical record was initiated on 9/23/25. Resident was admitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 9/4/25, showed Resident 18 had the capacity to understand and make decisions. Review of Resident 18's Order Summary Report showed a physician's order dated 9/3/25, for hemodialysis Mondays-Wednesday-Fridays and Dialysis Center 1. Review of Resident 18's progress notes for the scheduled dialysis days on 9/5, 9/8, and 9/10/25, failed to show Resident 18 left the facility for dialysis as ordered by the physician. However, Resident 18's progress notes on 9/8/25 at 1746 hours written by LVN 5, showed Resident 18 arrived at 1730 hours from the dialysis center with incomplete dialysis information. Review of the facility's investigation regarding Resident 18's missed dialysis was completed on 9/12/25. The investigation concluded Resident 18 did not go to his scheduled dialysis and the reason why resident did not go was not known since Resident 18 was transferred to the acute care hospital on 9/9/25 at 1900 hours. On 9/23/25 at 1245 hours, a telephone interview was conducted with Dialysis Center 1 Facility Administrator. Dialysis Center 1 Facility Administrator stated Resident 18 was not dialyzed on site from 8/25 through 9/12/25. Dialysis Center 1 Facility Administrator further stated the SNF had called and was told Resident 18 could not make it to the dialysis center because the facility was unable to arrange transportation. On 9/23/25 at 1300 hours, an interview and concurrent medical record review was conducted with the Director of Business Development (DBD), who works with the Admissions Department. The Director of Business Development stated she confirmed the resident's transportation and dialysis center arrangements prior to and on the day of Resident 18's admission to the facility. On 9/24/25 at 1040 hours, an interview was conducted with CNA 6, who was assigned to care for Resident 18 on 9/5 and 9/8/25, on the day shift. CNA 6 stated I remember him, and on my days with him, he did not go to dialysis. CNA 6 further stated I did not dress him up to go outside and verified he was assigned to care for Resident 18 on 9/5 and 9/8/25. CNA 6 was asked if he saw Resident 18 leaving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055121 If continuation sheet Page 9 of 15 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 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. 2. Medical record review for Resident 10 was initiated on 9/23/25. Resident 10 was admitted to the facility on [DATE]. 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: 055121 If continuation sheet Page 10 of 15 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 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], 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]. 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], 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: 055121 If continuation sheet Page 11 of 15 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 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 Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to follow the physician's order for one of 18 sampled residents (Resident 11). * The facility failed to administer lidocaine patches to Resident 11 per the physician's order. This failure had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Medication Orders dated 4/2008 showed medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Review of the facility's P&P titled Preparation and General Guidelines-Medication Administration dated 10/2017 showed the following:a. medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;b. medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications;c. medications are administered in accordance with written orders of the attending physician;d. medications are administered at the time they are prepared. Medications are not pre-poured;e. medication supplied for one resident are never administered to another resident;f. 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 11 was initiated on 9/3/25. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 8/17/25, showed Resident 11 had the capacity to make medical decisions. 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 Review of the facility's document titled Manifest dated 8/16/25, showed Resident 11 had a quantity of 14 Lidocaine 5% patches, and a quantity of 10 Asperflex Lidocaine 4% patches delivered to the facility. 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 and concurrent interview was conducted with the DON. The DON verified the lidocaine patch for Resident 11 was not applied. The DON verified the 4% Asperflex was not in Medication Cart 1, and the 5% Lidocaine patch contained 14 patches. On 9/25/25 at 1509 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the Lidocaine 5% patch was found in central supply but was not refilled in the medication cart. The DON verified the medication cart containing 14 patches of Resident 11's 5% lidocaine. The DON stated since Resident 11 was not administered his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055121 If continuation sheet Page 12 of 15 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 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 F842. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055121 If continuation sheet Page 13 of 15 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 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 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurate for two of 18 sampled residents (Residents 8 and 11). * The facility failed to ensure Resident 8's Monitor Record was accurate and complete. *The facility failed to ensure Resident 11's MAR was accurate. These failures had the potential for Resident 8 and 11's care needs not being met as the medical records were inaccurate.Findings 1. 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. Review of Resident 8's Order Summary Report showed a physician's order dated 5/21/25, to monitor for the behavior of getting up unassisted and record the number of times the behavior was manifested every shift. Review of Resident 8's Progress Note dated 9/14/25, showed the resident was found on the floor next to the bedroom door. The resident reported no pain or discomfort, and was able to make needs known. The resident's vital signs were within normal limits. Review of Resident 8's Skin assessment dated [DATE], showed Resident 8 sustained two new skin tears due to fall. Review of Resident 8's Monitor Record for September 2025 showed the following: - there were no entries on 9/4, 9/5, 9/6, and 9/20/25, for the monitoring of the behavior of getting up unassisted and recording the number of times the behavior was manifested every shift. - there was inaccurate documentation on 9/14 and 9/16/25, when it was coded as 0 incidents of getting up unassisted instead of two incidents per above. On 9/23/25 at 1000 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the missing entries in the Monitor Record on 9/4, 9/5, 9/6 and 9/20/25. The DON stated Resident 8 had history of putting himself on the floor and those instances should have been documented on those dates. The DON also verified the entries on 9/14 and 9/16/25 were inaccurately documented as 0 because the resident got up unassisted and experienced unwitnessed falls on those dates. The DON stated the instances should have been documented as two instead of 0. On 9/25/25 at 1440 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above undocumented and inaccurate entries and stated the nurses did not complete the documentation. 2. Review of the facility's P&P titled Preparation and General Guidelines-Medication Administration dated 10/2017 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055121 If continuation sheet Page 14 of 15 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 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]. 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 F755 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055121 If continuation sheet Page 15 of 15