Resident 10 had been admitted to the facility months earlier with a surgical wound that included sutures. Staff failed to assess, monitor, document or provide care for the wound until September 2, when they finally located it during a comprehensive examination that also revealed other previously unknown wounds requiring treatment.
The resident had capacity to understand and make decisions, according to his medical records. But he consistently refused multiple aspects of his care plan, including dialysis treatments, medication administration, skin assessments and repositioning to prevent pressure injuries.
His refusals created a cascade of medical problems. The wound care nurse told inspectors that Resident 10 had refused dialysis for two weeks straight, ultimately requiring hospitalization. On September 24, medical notes showed he was still refusing both wound care and dialysis, again necessitating hospital treatment.
During a September 23 interview, the wound care nurse verified that Resident 10 "frequently refused all aspects of his plan of care." The nurse believed the surgical wound and sutures remained hidden for months specifically because of the resident's consistent refusal of skin assessments.
Nobody developed a care plan to address his refusals.
Federal inspectors found that despite Resident 10's documented pattern of refusing dialysis, repositioning, medications and skin assessments, facility staff never created a comprehensive strategy to work with his resistance. The Director of Nursing confirmed during a September 24 interview that no care plan existed to address the resident's multiple refusals of care.
"The DON verified the resident's refusals should have been incorporated into the resident's plan of care," inspectors wrote.
The missed surgical wound represented the most serious consequence of this planning failure. The Director of Nursing acknowledged that staff missed the surgical site because of the resident's frequent refusal of skin assessment and care.
When inspectors observed Resident 10 on September 25, he was refusing wound care treatment. The wound care nurse reported he had also refused his medications and dialysis that same morning, continuing the pattern that had led to his previous hospitalizations.
The facility's failure extended beyond the individual resident. Inspectors found that staff had not developed systematic approaches for residents who refuse care, despite federal requirements that nursing homes create comprehensive, person-centered care plans addressing individual needs and behaviors.
Resident 10's case illustrated how refusal of care can mask serious medical conditions when facilities lack proper protocols. His surgical wound required immediate attention once discovered, but the months of neglect had allowed complications to develop unchecked.
The interdisciplinary team noted his care refusals as early as September 2, but documentation showed no corresponding care plan modifications to address his resistance or ensure critical medical needs were still being met through alternative approaches.
Federal regulations require nursing homes to develop complete care plans with measurable actions and timetables that meet all resident needs. When residents refuse care, facilities must adapt their approaches rather than simply documenting the refusals without intervention.
The wound care nurse's September interview revealed the broader implications of the planning failure. Beyond the hidden surgical wound, Resident 10's refusal of repositioning put him at risk for pressure injuries, while his medication refusals and dialysis interruptions created life-threatening complications requiring repeated hospitalizations.
The Administrator and Director of Nursing confirmed all inspection findings during a September 26 telephone interview, acknowledging their facility's failure to develop appropriate care planning for a resident whose medical complexity demanded specialized intervention strategies.
Resident 10's surgical wound, finally discovered and treated in September, represented months of missed opportunities for proper medical care while he remained at the Newport Beach facility without adequate planning for his documented pattern of care refusal.
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.