Inspection Reports for
Pelican Pointe Health and Rehabilitation Center
710 3RD ST, WINDSOR, CO, 80550-5484
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8 CMS Surveys
Inspection Report — Jul 15, 2025
Complaint Investigation
Date: Jul 15, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse and failure to protect residents from physical abuse in the facility.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident physical abuse involving Resident #4 and others. The facility failed to timely investigate, intervene, and update care plans to prevent further abuse. Immediate jeopardy was identified due to the risk of serious harm to residents.
Findings
The facility failed to protect residents from repeated resident-to-resident physical abuse, particularly by Resident #4 who exhibited escalating aggressive behaviors toward multiple cognitively impaired residents. The facility also failed to conduct timely investigations, update care plans, implement effective interventions, and provide adequate supervision. Immediate jeopardy was identified but later abated with a plan of correction. Additional deficiencies included failure to ensure the acting nursing home administrator's license was valid and failure to maintain an effective quality assurance program.
Deficiencies (3)
F0600: The facility failed to protect residents from all types of abuse, including repeated resident-to-resident physical abuse by Resident #4 and others, resulting in immediate jeopardy to resident health or safety.
F0839: The facility failed to ensure professional staff was licensed, certified, or registered in accordance with applicable State laws, specifically the acting nursing home administrator's license was expired.
F0867: The facility failed to implement an effective quality assurance program to identify and address quality deficiencies, including failure to identify and address abuse concerns that led to immediate jeopardy.
Report Facts
Residents affected by abuse: 6
Dates of incidents: 7
Duration of 15-minute checks: 72
BIMS scores: 4
BIMS scores: 3
BIMS scores: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Witnessed multiple incidents of aggression involving Resident #4 and reported observations. |
| DON | Director of Nursing | Acting as temporary Nursing Home Administrator during survey; involved in plan of correction and interviews. |
| AIT | Administrator in Training | Notified of immediate jeopardy and involved in plan of correction. |
| RN #4 | Registered Nurse | Interviewed regarding resident behaviors and care plan documentation. |
| CNA #9 | Certified Nursing Assistant | Interviewed about facility procedures and resident behaviors. |
| CNA #10 | Certified Nursing Assistant | Contract employee unaware of resident behaviors and interventions until survey. |
| Medical Director | Medical Director | Interviewed about oversight and involvement in quality assurance and clinical practice. |
Inspection Report — Feb 4, 2025
Complaint Investigation
Date: Feb 4, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to promptly resolve grievances related to missing personal items of Resident #3, including cell phones and eye glasses.
Complaint Details
The complaint investigation focused on Resident #3's grievances about missing personal items. The grievance official did not complete required grievance forms or follow-up documentation. The grievance was substantiated as the facility failed to act promptly or document actions until after the survey.
Findings
The facility failed to document and follow-up on grievances reported by Resident #3 concerning missing personal items. The grievance process was not properly executed, and there was no timely resolution or adequate safeguarding measures until after the survey identified the issues.
Deficiencies (1)
F 0585: The facility failed to ensure residents and their representatives were provided prompt efforts to resolve grievances. Specifically, the facility did not document or follow-up on grievances related to missing cell phones and eye glasses for Resident #3.
Report Facts
Residents reviewed for grievances: 8
Sample residents: 14
Missing cell phones: 5
Missing pairs of eye glasses: 5
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Responsible for grievance process and interviewed regarding missing items and grievance documentation | |
| Nursing Home Administrator | Interviewed about awareness of missing items and grievance process |
Inspection Report — Jun 10, 2024
Routine
Date: Jun 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and infection control at Pelican Pointe Health and Rehabilitation Center.
Findings
The facility failed to ensure residents dependent on staff for activities of daily living received scheduled showers and personal hygiene assistance. The facility also failed to prevent elopement risks adequately, investigate elopement incidents, maintain accurate elopement risk assessments, and ensure proper functioning and monitoring of wander prevention devices. Additionally, the infection prevention program was deficient, with staff failing to perform proper hand hygiene and disinfect glucometers according to manufacturer instructions.
Deficiencies (3)
F 0677: The facility failed to provide scheduled showers and shaving assistance to residents dependent on staff for activities of daily living, resulting in inadequate personal hygiene for three residents.
F 0689: The facility failed to provide adequate supervision and safety measures to prevent elopement, did not investigate an elopement incident, lacked physician orders for wanderguard use and monitoring, and failed to maintain accurate care plans and risk assessments for residents with wander prevention devices.
F 0880: The facility failed to maintain an effective infection prevention program by not ensuring staff performed hand hygiene before and after blood glucose checks and by not disinfecting glucometers with appropriate contact time between uses.
Report Facts
Residents reviewed for ADL care: 10
Residents affected by ADL deficiencies: 3
Residents reviewed for accident hazards: 10
Residents affected by accident hazard deficiencies: 4
Residents reviewed for infection control: 3
Inspection Report — Dec 11, 2023
Complaint Investigation
Date: Dec 11, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident grievance about alleged tampering with milk by a dietary aide.
Complaint Details
The complaint investigation involved Resident #5's allegation that dietary aide #1 was adding sugar to his milk to raise his blood sugar. The grievance was not documented or resolved by the facility. The complaint was substantiated with findings of failure to address the grievance.
Findings
The facility failed to provide a prompt resolution to Resident #5's grievance concerning sugar being added to his milk by a dietary aide. The grievance process was not properly documented, and the facility had not addressed the resident's concerns despite multiple reports.
Deficiencies (1)
F 0585: The facility failed to ensure Resident #5 was provided prompt efforts to resolve grievances. Resident #5 alleged a dietary aide added sugar to his milk, but the facility did not document or resolve the grievance.
Report Facts
Residents reviewed for grievances: 40
Resident #5 BIMS score: 14
Resident #5 hand washing frequency: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA | Nursing Home Administrator | Responsible for grievance process and interviewed regarding grievance documentation |
| DM | Dietary Manager | Interviewed about Resident #5's concerns and began ordering individual milk cartons |
| LPN #1 | Licensed Practical Nurse | Interviewed and noted Resident #5's diagnosis and concerns about milk |
| CNA #12 | Certified Nurse Aide | Interviewed about attempts to open milk in front of Resident #5 |
Inspection Report — Dec 11, 2023
Annual Inspection
Date: Dec 11, 2023
Visit Reason
Annual recertification survey and complaint investigations to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including grievance resolution, abuse prevention and reporting, nutritional care, dementia care programming, medication management, infection control, immunization tracking, emergency equipment maintenance, and staff training compliance.
Deficiencies (16)
F0585: Facility failed to provide prompt resolution to Resident #5's grievance regarding sugar in milk despite multiple reports.
F0600: Facility failed to prevent resident-to-resident physical abuse incidents involving Residents #30, #47, #75, and #12 and did not provide adequate supervision.
F0609: Facility failed to timely report an allegation of resident abuse by staff involving Resident #12 to proper authorities.
F0658: Facility failed to ensure Resident #6's vital signs were monitored immediately before administration of blood pressure medication as ordered.
F0660: Facility failed to develop and document effective discharge plans for Residents #60 and #78, including resident goals and interventions.
F0692: Facility failed to provide timely and effective nutritional interventions for Resident #54 experiencing significant weight loss, including inconsistent meal intake documentation and delayed supplement initiation.
F0744: Facility failed to provide consistent, meaningful, and person-centered dementia care activities for residents in the secured dementia care unit, including Residents #30, #40, and #4.
F0761: Facility failed to ensure all drugs and biologicals were properly stored and labeled, including expired medications in medication carts and refrigerators and undated opened tuberculin vial.
F0806: Facility failed to provide food accommodating Resident #58's preferences, including lack of coffee availability despite resident preference.
F0838: Facility failed to conduct and document a comprehensive facility-wide assessment including staff competencies, training needs, and resources for day-to-day and emergency resident care.
F0867: Facility failed to implement an effective quality assurance program to identify, monitor, and correct deficiencies, including failure to address pneumococcal vaccination compliance.
F0880: Facility failed to maintain infection control practices including incomplete COVID-19 vaccination tracking, improper cleaning of resident rooms and bathrooms, improper disposal of sharps and razors, unsanitary foley catheter and incontinence care, and improper disposal of suction canisters.
F0908: Facility failed to maintain emergency crash carts in safe operating condition including missing and expired supplies, lack of staff training on cart operation and oxygen use.
F0943: Facility failed to provide required abuse identification, prevention, and reporting training to 17 newly hired nursing staff between 10/1/23 and 12/6/23.
F0944: Facility failed to provide mandatory training on the facility's Quality Assurance and Performance Improvement (QAPI) program to 17 newly hired nursing staff between 10/1/23 and 12/6/23.
F0949: Facility failed to provide behavioral health and dementia management training to 17 newly hired nursing staff between 10/1/23 and 12/6/23.
Report Facts
Weight loss percentage: 10.25
Weight loss percentage: 12.42
Number of nursing staff without abuse training: 17
Number of nursing staff without QAPI training: 17
Number of nursing staff without behavioral health training: 17
Number of residents reviewed for immunizations: 12
Inspection Report — Aug 7, 2023
Complaint Investigation
Date: Aug 7, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to maintain a safe, clean, and comfortable environment in resident rooms and to ensure appropriate neurological assessments were conducted following resident falls.
Complaint Details
The complaint investigation focused on the facility's failure to maintain a safe and clean environment in resident rooms and failure to conduct required neurological assessments after resident falls. The investigation substantiated these issues, noting multiple environmental deficiencies and lack of neurological assessments for Resident #10 after three falls.
Findings
The facility failed to maintain resident rooms in a sanitary and comfortable manner on two of five halls, with multiple maintenance and housekeeping deficiencies observed. Additionally, the facility failed to conduct neurological assessments for a resident following three unwitnessed falls, despite documented injuries and policy requirements.
Deficiencies (2)
F 0584: The facility failed to maintain resident rooms on two of five halls in a safe, clean, and comfortable manner, with issues including loose cove bases, chipped paint, holes in walls, missing light fixtures, bugs in ceiling light fixtures, and wet towels around toilets.
F 0684: The facility failed to ensure neurological assessments were started and completed for Resident #10 following three unwitnessed falls, despite injuries including fractures, lacerations, and contusions, and despite policy requiring such assessments.
Report Facts
Resident falls: 3
Resident bathroom floors replaced: 6
Inspection Report — Aug 25, 2022
Date: Aug 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and clean environment, inadequate supervision and management of residents with dementia exhibiting inappropriate sexual behaviors, medication errors involving antipsychotic administration, failure to maintain ice machines and pest control, and lack of coordination with hospice services.
Deficiencies (8)
F0584: The facility failed to follow the cleaning schedule and properly clean resident wheelchairs and walkers on memory care units, leading to unsanitary conditions for five residents.
F0600: The facility failed to prevent inappropriate sexual behavior among three cognitively impaired residents on the male secure unit, including inadequate monitoring and staff education.
F0689: The facility failed to ensure Resident #8's Wanderguard was checked visually and electronically as ordered, with multiple missed documented checks from March to August 2022.
F0744: The facility failed to provide appropriate treatment and services to three residents with dementia, including failure to develop person-centered interventions and adequately monitor behaviors.
F0760: The facility failed to prevent a significant medication error when Resident #46 did not receive prescribed long-acting Haldol on three occasions and was given short-acting Haldol in error.
F0812: The facility failed to properly clean and maintain ice machines in the main kitchen and dining room, resulting in visible residue and dust accumulation.
F0849: The facility failed to collaborate with the hospice provider for Resident #53 by not obtaining the hospice care plan or service notes and failing to incorporate hospice care into the resident's plan.
F0925: The facility failed to maintain an effective pest control program, resulting in flies present in resident rooms, hallways, dining room, and kitchen areas.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: Many
Missed medication doses: 3
Missed Wanderguard checks: 50
Inspection Report — Jun 15, 2021
Routine
Date: Jun 15, 2021
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident care, staffing, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to prevent resident-to-resident abuse, insufficient nursing staff, inadequate dementia care, improper medication and respiratory care, poor food quality and service, improper medication storage and labeling, and lapses in infection control practices.
Deficiencies (13)
F550: Facility failed to ensure eight residents were treated with dignity and respect, including timely response to call lights and adequate staffing.
F565: Facility failed to follow-up on grievances from a group of eight residents regarding staffing, dignity, and activity programming.
F585: Facility failed to provide prompt efforts to resolve a grievance regarding a missing personal item for one resident.
F600: Facility failed to prevent resident-to-resident physical and verbal abuse involving multiple residents on secured units.
F603: Facility failed to ensure residents had the right to be free from involuntary seclusion on the secure unit, including proper assessment and documentation for continued stay.
F695: Facility failed to provide safe and appropriate respiratory care, including administering oxygen as ordered and labeling oxygen tubing.
F697: Facility failed to provide safe, appropriate pain management for one resident, including thorough pain evaluation, timely medication administration, and accurate narcotic records.
F725: Facility failed to provide sufficient nursing staff to meet resident needs, resulting in multiple care deficiencies including dignity, abuse prevention, and dementia care.
F744: Facility failed to provide appropriate treatment and services to residents with dementia to maintain highest practicable well-being, including meaningful activities and meal assistance.
F761: Facility failed to ensure all drugs and biologicals were labeled with open dates, medication carts were secured when unattended, and personal food was not stored in medication refrigerators.
F804: Facility failed to ensure food was palatable, attractive, and served at appropriate temperatures, including bland and unseasoned food and lack of fresh fruit.
F814: Facility failed to properly dispose of garbage and maintain dumpster lids closed to prevent pest harborage.
F880: Facility failed to maintain an infection control program, including improper PPE use and hand hygiene by staff, failure to ensure residents wore masks outside rooms, and improper housekeeping hand hygiene.
Report Facts
Residents with dementia: 57
Residents with behavioral healthcare needs: 49
Open nursing positions: 10
Medication discrepancies: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen therapy and medication administration |
| DON | Director of Nursing | Interviewed regarding staffing, medication, infection control, and grievance processes |
| NHA | Nursing Home Administrator | Interviewed regarding staffing, grievance processes, and food quality |
| CNA #1 | Certified Nurse Aide | Interviewed regarding staffing and resident care |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident meal assistance and abuse prevention |
| CNA #4 | Certified Nurse Aide | Interviewed regarding dementia care training |
| CNA #5 | Certified Nurse Aide | Interviewed regarding resident wandering and secure unit criteria |
| CNA #6 | Certified Nurse Aide | Interviewed regarding secure unit admission criteria |
| CMA | Certified Medication Aide | Interviewed regarding pain medication administration |
| HSK #1 | Housekeeper | Observed and interviewed regarding cleaning and hand hygiene practices |
| SDC | Staff Development Coordinator / Infection Preventionist | Interviewed regarding infection control and PPE |
| CNC | Corporate Nurse Consultant | Interviewed regarding infection control and housekeeping practices |
| DM | Dietary Manager | Interviewed regarding food quality and dumpster conditions |
| DC | Dietary Consultant | Interviewed regarding food quality and dumpster conditions |
| MTD | Maintenance Director | Interviewed regarding dumpster conditions and staffing |
| RN #4 | Registered Nurse | Interviewed regarding staffing and workload |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding staffing and nurse coverage |
| RN #2 | Registered Nurse | Interviewed regarding staffing and call-offs |
| CNA #10 | Certified Nurse Aide | Interviewed regarding staffing and float assignments |
| MTD | Maintenance Director | Interviewed regarding staffing and call-offs |
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