Pelican Pointe Healthcare and Rehabilitation

Inspectors wroteBased on record reviews, interviews, and review of the facility's policies and procedures, the facility failed to ensure staff implemented the facility's policy for advanced directives for 1 (#95) of 1 (#95) resident investigated for advance directives.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that nurses possessed competencies and skill sets necessary to provide nursing services to meet the residents' needs safely as evidenced by S2LPN (Licensed Practical Nurse) failing to administer medications according to the facility's policies and procedures and rights of medication administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure that all grievances were thoroughly investigated to include the pertinent findings or conclusions regarding the resident's concerns for 1 (#41) out of 39 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) for anticoagulant use for 1 (Resident #9) out of 2 (Resident #9 and #38) residents reviewed for resident assessment discrepancy for anticoagulants.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive person-centered care plan that included orders for an AFO (Ankle Foot Orthosis) brace for 1 (#41) out of 2 (#41, #64) residents investigated for positioning and mobility out of a total sample of 39 residents.

Inspectors wroteBased on observations, interviews and record review the facility failed to revise the care plan to include an appropriate fall intervention after a resident fell for 1 (#89) of 3 (#9, #75 and #89) residents investigated for accidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident received services consistent with accepted professional standards and the resident's comprehensive person-centered care plan by the nursing staff failing to document that a resident's dialysis site was assessed and monitored daily for 1 (#107) out of 1 (#107) resident investigated for dialysis.

Inspectors wroteBased on observation, record review and interview, the facility's nursing staff failed to demonstrate appropriate competency and skills as evidenced by failing to assess and report bruises for 1 (#41) out of 3 (#12, #41, #56) residents investigated for skin conditions out of a total sample of 39 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide an assistive device at meal times for 1 (#13) of 5 residents who used assistive devices at mealtimes.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure refrigerated food items that were opened were cleaned and labeled with the date they were opened before storing. This deficient practice had the potential to affect the 115 residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that staff and resident wore the appropriate PPE (personal protective equipment) for a resident on contact transmission based precautions (TBP) for 1 (#9) of 1 (#9) resident in the facility on TBP. This deficient practice had the potential to affect 115 residents who resided in the facility.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to conduct regular inspections of beds for proper mattress fit for the bed's frame for 1 (Resident #9) out of 3 (Resident #9, #75 and #89) residents investigated for accidents.

Inspectors wroteBased on interviews and record reviews, the facility failed to coordinate hospice care services for 4 (#1, #2, #3, and #R1) out of 4 (#1, #2, #3, and #R1) residents reviewed for hospice care. The facility failed to: 1. allow Residents #1, #2, #R1 and or their RP (Responsible Party) the choice of hospice provider. 2. obtain the initial certification and or most recent recertification of terminal illness and most recent hospice POC (plan of care) for Residents #1, #2, #3, and #R1, and 3. immediately notify the hospice agency when there was an incident of alleged abuse towards Resident #R1.

Inspectors wroteBased on record review, review of the facility's policy and procedure, and interviews the facility's staff failed to immediately report an incident of alleged abuse to the Administrator/ DON (Director of Nursing) for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for abuse.

Inspectors wroteBased on record review, review of the facility's policy, and interviews the facility's staff failed to ensure an allegation of abuse was thoroughly investigated for 2 (#1 and #2) out of 4 (#1, #2, #3, and #4) residents reviewed for abuse.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide reasonable accommodations of the resident's needs by failing to ensure the call light in the resident's room was in reach for 1 (#1) resident out of 3 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff possess competencies and skill sets necessary to provide nursing services to meet the residents' needs safely by failing to ensure neurological checks were initiated and/or completed after unwitnessed falls for 2 (#1, #2) residents out of 3 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident as evidence by failing to ensure there were specific indicators and parameters for Acetaminophen (Tylenol) for 1 (#3) resident out of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records. The facility had a total census of 64 residents.

Inspectors wroteBased on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#59) of 40 sampled residents. This was evidenced when: 1. facility staff failed to apply left wrist splint while out of bed. 2. facility staff failed to apply right hand splint per physician order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for 1 (#52) out of 2 residents (#46 and #52) investigated for environment by failing to ensure that the resident's wheelchair and wheelchair pad were cleaned. This deficient practice had the potential to affect all residents in the facility who used a wheelchair.