The resident was admitted in April with a surgical wound on the left lateral thoracic region secured with three sutures. Hospital transfer orders specifically noted the incision site on the left upper chest with dressing in place and instructed staff to follow wound team recommendations and standard nursing protocols for wound care.
Staff never developed a baseline care plan to address the surgical wound.
The facility didn't provide any wound care until September 2nd, federal inspectors found during a complaint investigation completed September 25th.
"This failure resulted in the resident's care needs not being met and had the potential to affect the resident's well-being," inspectors wrote.
Federal regulations require nursing homes to create care plans addressing residents' most immediate needs within 48 hours of admission. The baseline care plan serves as a roadmap for staff to provide essential care while a comprehensive assessment is completed.
Review of the resident's medical records revealed no baseline care plan problem was developed to address the surgical wound and required care for the incision with sutures, despite clear documentation of the wound's presence at admission.
Hospital transfer orders from April 17th showed the resident had an incision site on the left upper lateral chest with dressing in place. The wound care section specifically instructed staff to follow current wound team recommendations and standard nursing protocols.
The Director of Nursing confirmed during an interview that the resident was admitted with a surgical wound on the left lateral thoracic region with three sutures. The DON verified that no baseline care plan problem was developed within 48 hours of admission to address the surgical wound.
During a follow-up telephone interview, both the Administrator and Director of Nursing were informed of the findings and verified the inspection results.
The gap in care lasted from the resident's April admission until September 2nd, when wound care finally began. For nearly five months, the surgical incision with sutures received no documented assessment, monitoring or treatment despite hospital orders requiring ongoing wound care.
Surgical wounds require careful monitoring to prevent infection and ensure proper healing. Sutures indicate the incision was significant enough to require surgical closure, making ongoing wound care particularly critical.
The inspection was conducted as part of a complaint investigation, suggesting someone reported concerns about care at the facility. Inspectors sampled 18 residents' records and found the wound care failure affected one resident.
Pelican Ridge Post Acute is located on Flagship Road in Newport Beach. The facility received a citation for failing to meet federal standards requiring prompt development of baseline care plans to address residents' immediate needs.
The deficiency was classified as causing minimal harm or potential for actual harm to few residents. However, the prolonged period without wound care for a surgical incision with sutures represented a significant gap in basic medical care.
Federal inspectors noted the violation cross-referenced another deficiency, suggesting related problems with care planning or wound management at the facility.
The resident's surgical wound finally received attention in September, but only after months without the monitoring and treatment specified in hospital transfer orders. By that time, the three-sutured incision had gone without documented assessment or care for nearly five months following the April admission.
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.