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Pelican Ridge Post Acute: Wound Care Failures - CA
The failure came to light during a complaint inspection on September 25, 2025....
Latest reports, citations, and penalties from CMS data
The failure came to light during a complaint inspection on September 25, 2025....
The Director of Nursing, identified in inspection records as V2, confirmed on September 24 that staff were expected to follow all five of those standards....
The inspection, completed September 24, 2025, examined what happened between two residents identified in the report as R4 and R5....
Inspectors arrived on September 23, 2025, just after one in the afternoon, and found all of it standing open....
A cognitive assessment scored the resident at 15 out of 15, meaning fully intact....
Not what staff were supposed to do when they found the prescribed dressings on the floor and homemade ones in their place....
For context, coffee served at 99 degrees is closer to body temperature than to what most people would recognize as a hot drink....
A mental status assessment completed in early April 2025 gave her a score of 4 out of 15, indicating severe cognitive impairment....
That is what federal health inspectors concluded after visiting Roane General Hospital in Spencer, West Virginia, on September 25, 2025....
A small number of residents were affected....
Pressure ulcers, sometimes called bedsores, develop when sustained weight against a surface cuts off blood flow to the skin....
That last part, the documentation, is not a clerical formality....
The citation, issued September 24, 2025, covered failures in both labeling and physical security of drugs and biologicals kept at the facility....
The citation, issued September 25, 2025, was one of five deficiencies inspectors documented during the visit....
The deficiency, tagged under pharmacy service failures, was classified as a pattern, meaning inspectors found this wasn't an isolated slip....
The resident, identified in inspection records as Resident 49, had a history of multiple falls....
That is nearly everything the inspection record says....
In the language of nursing home oversight, that distinction matters....
The citation, issued September 25, 2025, fell under a regulatory category covering trauma-informed and culturally competent care....
The resident, identified in inspection records only as Resident 1, collapsed on August 10, 2025....