Pelican Pointe Health and Rehabilitation Center

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of sexual abuse to the State Survey and Certification Agency in accordance with state law for two (#3 and #4) of two residents reviewed for abuse out of four sample residents. Specifically, the facility failed to ensure an incident of alleged sexual abuse between Resident #4 and Resident #3 was reported to the State Survey Agency.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#5) of six residents out of nine sample residents. Specifically, the facility failed to respond to Resident #5's failure to void following the removal of the resident's catheter in a timely manner, which delayed the resident's transfer to the hospital. Resident #5 was admitted to the facility on [DATE]. Resident #5 was sent to the emergency department on 4/30/26 and returned the same day with an indwelling (tubing placed in the bladder) catheter for urinary retention and an order for an antibiotic. On 5/12/26 at approximately 1:30 p.m. the resident's indwelling catheter was removed per the physician's orders. On 5/12/26 at 7:45 p.m. Resident #5 was sitting in the dining room and told the nurse he was not feeling well. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free of significant medication errors for one (#5) of six residents reviewed for medications errors out of nine sample residents. Specifically, the facility failed to ensure Resident #5 received antibiotics for a diagnosis of a urinary tract infection (UTI) per the physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to ensure Resident #5's indwelling catheter bag was not touching the floor.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of five residents reviewed for psychotropic medications out of 37 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to:-Ensure Resident #1 had behavior monitoring in place for antipsychotic use; and,-Ensure consents were obtained prior to administration of psychotropic medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and personalized care for one (#9) of three residents out of 37 sample residents. Specifically, the facility failed to revise Resident #9's care plan to address catheter care interventions for the prevention of recurrent urinary tract infections (UTI).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#78 and #70) of three residents reviewed for pressure injuries out of 37 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing or worsening. Specifically the facility failed to:-Ensure staff consistently offloaded Resident #78's heels; and, -Ensure staff consistently provided wound care to Resident #78 and Resident #70 in a timely manner, per physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#10) of one resident reviewed for dialysis out of 37 sample residents. Specifically, the facility failed to consistently complete the communication form used for dialysis communication for Resident #10Findings include:I. Facility policy and procedureThe Dialysis (Renal), Pre and Post-Care policy and procedure, revised April 2025, was received from the regional consultant on 1/15/26 at 9:02 a.m. It read in pertinent part, Assist resident in maintaining homeostasis pre- and post-renal dialysis; assess and maintain patency of renal dialysis access; assess resident daily for function related to renal dialysis; [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four units. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene and gown changes while performing wound care for Resident #61; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care and transfers for Resident #70, who was on enhanced barrier precautions (EBP) for wounds.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for one (#8) of five residents out of 37 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of side effects and adverse reactions were monitored and identified for Resident #8 while the resident was receiving prescribed antibiotics.

Inspectors wroteBased on observation, record review and interviews, the facility failed to create an environment that protected residents from resident-to-resident abuse. This affected six (#2, #3, #5, #6, #8 and #10) of 10 residents out of 12 sample residents residing on three of five units (Mountain View South, Sunrise South, and Mountain View North) in the facility. 1. Resident-to-resident abuse on the Mountain View South UnitResident #4, with severe cognitive loss, exhibited physical aggression toward four residents (#2, #3, #5, and #10), all of whom were cognitively impaired and resided with Resident #4 in the Mountain View South unit. Resident #4 was known to wander aimlessly and in and out of other residents' rooms, and to significantly intrude on the privacy of others. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure professional staff was licensed, certified, or registered in accordance with applicable State laws. Specifically, the facility failed to ensure the acting nursing home administrator's (NHA) license was valid.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome was likely to occur.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents and their representatives were provided prompt efforts by the facility to resolve grievances for one (#3) of eight residents reviewed for grievances out of 14 sample residents. Specifically, the facility failed to document and follow-up on grievances reported by Resident #3 regarding a missing cell phone and eye glasses.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#1, #3 and #5) of three residents reviewed out of 10 sample residents. Specifically, the facility failed to: -Ensure Resident #1, Resident #3 and Resident #5, who were dependent on staff for bathing, received their scheduled showers; and, -Ensure resident #5, who was dependent on staff for ADL care, received assistance with shaving.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for four (#4, #7, #8 and #9) of five residents reviewed for accident hazards out of 10 sample residents. Specifically, the facility failed to: -Provide supervision to prevent the elopement of Resident #4; -Investigate how Resident #4, who had a wander prevention device, eloped from the facility in order to prevent a recurrence; -Complete accurate elopement risk assessments for Resident #7 and Resident #8; -Ensure Resident #8 and Resident #9's care plans were updated to include their wander risk and wanderguards; and, -Routinely check the function of wander prevention devices for Resident #7, Resident #8 and Resident #9.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff performed hand hygiene with blood glucose checks; and, -Ensure glucometers were cleaned and disinfected with appropriate disinfectant contact time between uses.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss timely in one (#54) of seven residents out of 40 sample residents. Resident #54, who was identified as being at increased nutritional risk related to decreased oral intake and Alzheimer's disease, experienced a significant weight loss of 10.25% in a one month period of time and 12.42% in a three month period. The facility failed to ensure effective and timely interventions were in place to monitor, identify and prevent Resident #54's significant weight loss. The facility failed to monitor weekly weights, failed to consistently monitor meal intakes and failed to offer snacks when the resident refused or slept through meals. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to: -Obtain committee feedback; collect data; monitor adverse events; identify areas for improvement; prioritize improvement activities; implement corrective and preventative actions; and conduct performance improvement projects related to problem-prone areas identified; and, -Address concerns related to the facility's failure to provide pneumonia vaccines as requested and per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure tracking, offering and administration of the COVID-19 vaccination; -Ensure professional standards of infection control were followed while cleaning resident rooms and resident room bathrooms, so they did not contaminate surfaces with water from the inside of the toilet bowl; -Ensure razors and sharps were disposed of properly in a biohazard container; -Ensure that foley catheter care and incontinence care were performed in a sanitary manner; and, -Ensure a used suction canister was disposed of in a sanitary manner.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for 12 (#6, #59, #42, #47, #76, #75, #17, #35, #5, #27, #232 and #233) of 12 residents reviewed for immunizations out of 40 sample residents. Specifically the facility failed to: -Offer Resident #6 an annual influenza vaccination; -Offer Resident #59 and Resident #75 a pneumococcal vaccination upon admission; -Ensure Resident #42, Resident #47, Resident #76 and Resident #5's electronic medical records (EMR) were up to date with immunization records; -Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #42, Resident #47, Resident #76, Resident #35, Resident #5, Resident #232 and Resident #233; [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for four of four emergency (crash) carts. Specifically, the facility failed to: -Ensure staff completed daily equipment checks; -Ensure expired items were removed from the crash cart; -Ensure missing items were replaced on the crash cart; -Ensure staff knew how to open the crash carts; and, -Ensure staff were trained on how to use the emergency oxygen cylinders.

Inspectors wroteBased on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and resident abuse prevention; for 17 of 17 nursing staff hired between 10/1/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21), four resident aides (RA) (#1, #2, #3 and #4) one registered nurse (RN) (#6) and one licensed practical nurse (LPN) (#2) received training on abuse identification, prevention and reporting.

Inspectors wroteBased on interviews and record review, the facility failed to develop, implement, and maintain a mandatory effective training program for all staff, which includes, at a minimum, training on the facility's quality assurance and performance improvement (QAPI) program, including the goals and various elements of the program, how the facility intends to implement the program the staff's role in the facility's QAPI program and how to communicate concerns, problems or opportunities for improvement to the facility's quality assessment and assurance (QAA) committee for 17 of 17 nursing staff hired between 10/4/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21); four resident aide (RA) (#1, #2, #3 and #4); one registered nurse (RN) (#6); [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health based on requirements and as outlined in the facility's assessment, for 17 of 17 nursing staff hired between 10/4/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21), four resident aides (RA) (#1, #2, #3 and #4), one registered nurse (RN) (#6) and one licensed practical nurse (LPN) (#2) received training on behavioral health issues to include care specific to the individual needs of residents that are diagnosed with dementia and how to promote meaningful activities which promote engagement and positive meaningful relationships. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to effectively address the care and treatment needs of residents in the secured dementia care unit for the residents to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being; and provide person-centered care for three (#30, #40 and #4) of three residents reviewed for dementia care out of 40 sample residents. Specifically, the facility failed to provide the residents living in the Mountain View South with consistent and engaging activity programming of interest that was meaningful and person-centered. Additionally, the facility failed for Residents #30, #47 and #4 to: -Identify, address, and/or obtain necessary services to effectively meet the interests of the residents; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#5) of one resident reviewed for grievances out of 40 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #5's grievance, which the resident had communicated to staff on multiple occasions.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for two (#30 and #75) of two residents in two allegations of abuse reviewed out of 40 sample residents. Specifically, the facility failed to provide adequate supervision to prevent: -Resident #30 from being a victim of physical abuse by Resident #47; and, -Resident #75 from being a victim of physical abuse by Resident #12.

Inspectors wroteBased on staff interviews and record review, the facility failed to report alleged violations of potential abuse to the proper authority, including the policy and state oversight agency in accordance with state law for one alleged violations; involving one (#12) of one resident reviewed for allegations of abuse out of 40 sample residents. Specifically, the facility failed to report one allegation of resident abuse by staff to the facility administrator, director of nursing, local police or the State Agency, in a timely manner.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to provide services for one (#6) of two reviewed out of 40 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #6 vital signs-blood pressure and heart rate/pulse were monitored and assessed for irregularities immediately before the administration of a blood pressure medication.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge plan for two (#60 and #78) out of three residents reviewed for discharge planning out of 40 sample residents. Specifically, the facility failed to ensure the discharge planning process was documented in Resident #60 and Resident #78's medical record.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in one of two medication carts and two of four medication refrigerators. Specifically, the facility failed to: -Ensure that expired medications were removed from the medication carts and disposed of in a safe manner; -Ensure that an open tuberculin vial was dated upon opening; and -Ensure that an expired Pneumovax 23 vaccine was removed from the medication refrigerator in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for one (#58) of two residents out of 40 sample residents. Specifically, the facility failed to offer food choices according to resident preferences for Resident #58.

Inspectors wroteBased on record review and interviews, the facility failed to take effective steps to prevent inappropriate sexual behavior that involved three of five residents (#49, #225, and #35), all cognitively impaired, who resided on the facility's all male secure unit. Specifically, the facility failed to implement measures to prevent inappropriate sexual behavior between Resident #49 and Resident #225, inappropriate sexual behavior between Resident #49 and Resident #35, and the potential for inappropriate sexual behavior among other residents on the unit. Resident #225 was admitted to the facility's all male secure unit from a sister facility where he had exhibited sexually inappropriate behaviors toward female residents. [...]

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions. Specifically, the facility failed to ensure proper cleaning of the facility ice machines located in the main kitchen and main dining room according to manufacturer recommendations and facility policy.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure three (#225, #49, #35) of five residents with dementia out of 38 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop person-centered interventions to prevent the resident to resident altercations. Resident #225 was admitted to facility from another facility with known behaviors of sexual abuse towards female residents on his prior memory care unit. Upon admission, the resident was assessed by a medical director, who recommended increasing the number of staff on the secure unit to monitor the resident for his behaviors. He communicated his recommendations to the nursing home administrator (NHA). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment where resident's equipment necessary for the completion of activities of daily living was free from the potential spread of disease causing organisms for five (#3, #21, #57, #36, and #64) of 14 fourteen residents of 38 sample residents. Specifically, the facility failed to: -Follow the facility cleaning schedule for resident wheelchairs and walkers on memory care units; -Identify and clean unsanitary wheelchairs and walkers as needed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#8) of six out of 38 sample residents. Specifically, the facility failed to ensure Resident 8's Wanderguard was observed for placement and electronically checked for functionally as physician orders.

Inspectors wroteBased on record review and interview, the facility failed to ensure one (Resident #46) of one resident out of 38 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #46 received a prescribed monthly dose of long acting Haldol on three occasions (2/14/22 or 3/14/22 and 7/4/22), as ordered by the resident's physician. I. Professional reference According to [NAME] Nursing Drug Handbook 2020, Kizior, R. J. and [NAME], K.J., St. Louis Missouri 2020, revealed the following pharmaceutical information: -Page (pp). 561-563 read in part: Haloperidol (Haldol). Classification: First generation antipsychotic. Clinical: antipsychotic, .Uses: treatment of schizophrenia. Treats Tourette's disorder (controls tics and vocal utterances, .Management of psychotic disorder Therapeutic effect: [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to collaborate with the hospice provider to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (#53) resident out of 38 sample residents. Specifically, the facility failed to ensure for Resident #53: -Communication with the resident's hospice provider to obtain the providers care plan and treatment notes; and, -Failed to develop a comprehensive care plan to include the hospice provider's plan of care.