Pelican Pointe Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pelican Pointe Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 15, 2025

  Based 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. […]

• Actual harm, isolatedF684May 19, 2026

  Based 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. […]

• Actual harm, isolatedF692Dec 11, 2023

  Based 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. […]

• Actual harm, isolatedF600Aug 25, 2022

  Based 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. […]

• Actual harm, isolatedF689Feb 22, 2022

  Based on observations, record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#6) of six residents reviewed out of 15 sample residents. Resident #6 was on hospice services. The resident's minimum data set (MDS) assessment dated [DATE] revealed the resident required extensive staff assistance for transfers, requiring two plus persons' physical assistance. The resident had severe cognitive impairment. The care plan intervention dated 6/7/21 revealed the resident required a mechanical lift (Hoyer) with two staff assistance for transfers. The resident was inappropriately transferred by two staff members without the use of a mechanical Hoyer lift. […]