Pelican Pointe Health and Rehabilitation Center

Smoke Deficiencies

Install an approved automatic sprinkler system.

Construction Deficiencies

Use approved construction type or materials.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Services Deficiencies

Meet other general requirements that are deficient.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Administration Deficiencies

Employ staff that are licensed, certified, or registered in accordance with state laws.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Environmental Deficiencies

Keep all essential equipment working safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Develop a communication plan.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Resident Rights Deficiencies

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.

A survey for #CO1919339, Incident #1919340, Incident #1919341, Incident #1919342 and Incident #1919279 was conducted 7/14/25 to 7/15/25. Three deficiencies were cited. Based 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. Findings include:I. Facility policy and procedureThe Quality Assurance Performance Improvement (QAPI) policy and procedure, revised December 2024, was provided by the director of nursing (DON) on 7/15/25 at 1:00 p.m. It read in pertinent part, “It is the policy of this facility to develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, and to resolve ident.. Based 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. Findings include:I. Entrance interviewOn 7/14/25 at 9:00 a.m. the entrance conference was conducted with the director of nursing (DON). The DON said she was acting as the NHA at the time of the survey. The DON said there was a nursing home administrator in training who was preparing to become the permanent licensed NHA.II. Record reviewOn 7/14/25 at 9:15 a.m. a review was conducted on the State licensing website. The website showed the DON had applied for a temporary NHA license for emergency situations. The original issue and effective date was 4/2/25 and the expiration date was 7/1/25. The NHA temporary permit for emergency situations was listed as expired.On 7/14/25 at 2:10 p.m. the corporate operations director provided the license invoi.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

A survey prompted by #CO37380, #CO37418, #CO38757, Incident #37547, Incident #38374 and Incident #38375 was conducted 2/3/25 to 2/4/25. One deficiency was cited. Based 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.Findings include:I. Facility policy and procedureThe Grievances policy, dated December 2024, was provided by the nursing home administrator (NHA) on 2/4/25 at 2:07 p.m. It read in pertinent part,"It is the policy of this facility to establish a grievance process that allows residents a way to execute their right to voice concerns or grievances to the facility without fear of discrimination or reprisal. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the residents may have. "The facility' s grievance official is responsible for overseeing the grievance process and for receiving and tracking grievances and leading necessary investigations by the facility."The grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations."The grievance official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and misappropriation of resident property to the administrator and as required by state law."The grievance official responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken towards resolution."I. Resident statusResident #3, age 85, was admitted on 11/30/22. According to the February 2025 computerized physician orders (CPO), diagnoses included chronic kidney disease, dementia, hypertension (high blood pressure) and depression. The 10/25/24 minimum data set (MDS) assessment revealed Resident #3 had severe cognitive impairment with a brief interview for mental st..