Pelican Ridge Post Acute

In the surveyor’s words

From the most serious findings on record at Pelican Ridge Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jan 22, 2021

  Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to assign dedicated healthcare personnel (licensed nurse and CNA) to work only on the COVID-19 positive care unit (Red Zone). The facility assigned one licensed nurse (on all shifts) and one CNA (on most shifts) to provide resident care to both the COVID-19 positive and negative residents. […]

• No harm, potential for more than minimal, widespreadF812Nov 30, 2021

  Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen when: * The facility failed to ensure proper hand hygiene. * The facility failed to ensure the refrigerated food items were properly labeled and dated. * The facility failed to ensure the expired food items in the walk-in refrigerator were properly disposed. * The facility failed to ensure the cutting boards were in sanitary condition. * The facility failed to ensure the food contact surfaces had a smooth cleanable surface. * The facility failed to air dry the kitchen equipment. * The facility failed to ensure the kitchen equipment was clean. […]

• No harm, potential for more than minimal, patternF755Aug 20, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to follow their pharmaceutical procedures for one of 28 final sampled residents (Resident 9) and four nonsampled residents (Resident 20, 52, 107, and 154). * LVN 1 failed to prepare the correct physician's order dosage for Resident 9's gabapentin (medication to treat nerve pain) solution. This failure had the potential to negatively affect the resident's health condition. * The facility failed to reconcile Residents 20, 52, and 107's controlled medications with the MAR. […]

• No harm, potential for more than minimal, patternF761Aug 20, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to ensure proper storage, labeling, and disposal of the medications. * The keys for Medication Carts C and D were improperly stored inside of three-ring binders on top of each cart. * The destroyed medication incinerator's lid was not secured, resulting in medications previously destroyed and deemed unusable being accessible in their original intact form. * An opened PPD vial was not dated when opened. * The facility failed to ensure a topical medication in Treatment Cart A was labeled and dated with the open date. […]

• No harm, potential for more than minimal, patternF812Aug 20, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed. * The facility failed to ensure 30 individual boxes of milk was discarded after their expiration date. * The facility failed to ensure food preparation equipment was properly air-dried before storage. * The facility failed to ensure Dietary Aide 1 performed handwashing after removing hand mittens. These failures posed the risk of food-borne illnesses in highly susceptible resident population of 133 facility residents who received food prepared in the facility kitchen. Findings: Review of the facility's Total by Diet Texture dated 8/17/26, showed 133 of 140 residents consumed food prepared in the facility kitchen. 1. […]