Deficiency Records for Pelican Pointe Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Pelican Pointe Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-27 | 2024-01-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-27 | 2024-01-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-11 | 2023-12-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-11 | 2023-12-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-11 | 2023-12-29 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-12-11 | 2023-12-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-11 | 2023-12-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-12-11 | 2023-12-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-11 | 2023-12-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-11 | 2023-12-29 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-12-11 | 2023-12-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-11 | 2023-12-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-11 | 2023-12-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-11 | 2023-12-29 | N |
| Keep all essential equipment working safely. | Health | 2023-12-11 | 2023-12-29 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-12-11 | 2023-12-29 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-12-11 | 2023-12-29 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-12-11 | 2023-12-29 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-11 | 2023-12-29 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-11 | 2023-12-29 | N |
| Develop a communication plan. | Fire Safety | 2023-12-11 | 2023-12-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-11 | 2023-12-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-11 | 2023-12-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-07 | 2023-08-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-07 | 2023-08-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-25 | 2022-09-28 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-08-25 | 2022-09-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-25 | 2022-09-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-08-25 | 2022-09-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-25 | 2022-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-28 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-08-25 | 2022-09-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-25 | 2022-09-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-22 | 2022-04-29 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-22 | 2022-04-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-22 | 2022-03-24 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-22 | 2022-03-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-22 | 2022-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-22 | 2022-03-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-22 | 2022-03-19 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-13 | 2021-07-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-15 | 2021-07-22 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-15 | 2021-07-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-06-15 | 2021-07-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-15 | 2021-07-22 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-06-15 | 2021-07-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-15 | 2021-07-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-15 | 2021-07-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-06-15 | 2021-07-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-15 | 2021-07-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-15 | 2021-07-22 | N |
| Dispose of garbage and refuse properly. | Health | 2021-06-15 | 2021-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-15 | 2021-07-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-15 | 2021-07-22 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-13 | 2021-07-21 | N |
