Federal inspectors found the respiratory care failures during a September complaint investigation at Pelican Ridge Post Acute on Flagship Road. The violations affected two residents who required continuous positive airway pressure machines to treat obstructive sleep apnea, a condition where the upper airway repeatedly collapses during sleep.
Resident 4 had physician orders from September 10 requiring CPAP use every night and daily cleaning of the equipment according to manufacturer guidelines. When inspectors arrived on September 19 at 9:40 a.m., they found the resident's CPAP mask lying on the floor. The plastic bag meant to store the mask was missing from the room entirely.
Twenty-five minutes later, Licensed Vocational Nurse 4 picked the mask off the floor and placed it in a pink basin. The nurse confirmed there was no plastic bag available for proper storage and acknowledged that leaving the CPAP mask on the floor "could be a risk for infection."
The second case proved more severe. Resident 5 had been admitted to the facility with a physician's order dated September 11 for CPAP treatment at bedtime. Her care plan from September 17 specifically outlined interventions including applying the CPAP machine, evaluating lung sounds, monitoring for shortness of breath, and watching for periods when breathing stops during sleep.
Yet when inspectors checked her room on September 19, no CPAP machine was present.
"She has not had a CPAP machine since she was admitted to the facility," Resident 5 told inspectors during their 10:22 a.m. visit.
Registered Nurse 2 confirmed the problem five minutes later. The nurse verified that Resident 5 had active physician orders requiring CPAP application every night but acknowledged there was no CPAP machine at the resident's bedside. Resident 5 was receiving no CPAP treatment whatsoever.
The facility's own policy, revised in November 2021, requires that respiratory therapy be administered upon physician order or during emergencies by licensed nurses or respiratory therapists. The policy made no exceptions for equipment availability or storage problems.
Director of Nursing interviews revealed the scope of management awareness. At 10:44 a.m. on September 19, the DON acknowledged that Resident 4's CPAP mask should not have been on the floor. The DON also confirmed that Resident 5 lacked the required CPAP machine and was not receiving the physician-ordered treatment.
Sleep apnea represents a serious medical condition where breathing repeatedly stops and starts during sleep due to airway blockage. Without proper CPAP treatment, patients face increased risks of cardiovascular problems, daytime fatigue, and other health complications. The continuous positive airway pressure delivered through the mask prevents airway collapse and maintains normal breathing patterns.
For Resident 4, the unsanitary storage created potential exposure to floor contaminants, bacteria, and other pathogens that could cause respiratory infections. The missing storage bag violated basic infection control protocols for medical equipment that comes into direct contact with a patient's face and airways.
Resident 5's situation represented a complete failure to provide ordered medical treatment. Despite having a documented care plan that included monitoring for breathing interruptions and applying the CPAP machine, she received no respiratory support for her sleep apnea condition.
The inspection occurred following a complaint, suggesting someone reported concerns about the facility's respiratory care practices. Federal regulations require nursing homes to provide necessary medical treatments and maintain equipment in sanitary conditions to prevent infections.
Both the Administrator and Director of Nursing acknowledged the inspection findings on September 26, a week after the violations were documented. However, the inspection report provided no details about corrective actions or when proper CPAP equipment and storage would be provided to the affected residents.
The violations received a "minimal harm or potential for actual harm" rating from federal inspectors, who determined the failures had the potential to affect residents' respiratory health and well-being. The facility operates under Medicare provider number 055121 and serves residents requiring post-acute care services in Orange County.
For patients like Resident 5, each night without proper CPAP treatment meant continued exposure to the breathing interruptions and oxygen drops that characterize untreated sleep apnea.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Ridge Post Acute from 2025-09-25 including all violations, facility responses, and corrective action plans.