Inspection Reports for
Pelican Pointe Healthcare and Rehabilitation
405 MILTON ROAD, MAURICE, LA, 70555
Back to Facility Profile6 Reports
Inspection Report — Oct 1, 2025
Complaint Investigation CMS
Date: Oct 1, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to implement residents' advance directives and ensure nursing staff competency in medication administration.
Complaint Details
The investigation was triggered by complaints regarding failure to implement advance directives and medication administration errors. The findings confirmed these issues with substantiation.
Findings
The facility failed to update and adhere to residents' advance directives, resulting in inconsistent documentation for Resident #95. Additionally, a licensed practical nurse administered medication incorrectly due to discrepancies between physician orders and medication cards, indicating inadequate staff competency.
Deficiencies (2)
F 0578: The facility failed to ensure staff implemented the policy for advance directives for Resident #95, resulting in inconsistent code status documentation between the face sheet, care plan, and LaPOST.
F 0726: The facility failed to ensure nurses possessed competencies to safely administer medications, as evidenced by S2LPN administering an incorrect dosage of medication to Resident #100 due to conflicting physician orders and medication cards.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2LPN | Licensed Practical Nurse | Named in medication administration error involving Resident #100 |
| S1DON | Director of Nursing | Confirmed deficiencies related to advance directives and medication administration |
| S3RNCorp | Corporate Registered Nurse | Interviewed regarding advance directive inconsistencies for Resident #95 |
Inspection Report — Oct 9, 2024
Routine CMS
Date: Oct 9, 2024
Visit Reason
Routine inspection of Pelican Pointe Healthcare and Rehabilitation to assess compliance with regulatory standards across multiple areas including resident care, safety, infection control, and food service.
Findings
The facility was found deficient in several areas including grievance investigation, accurate resident assessments, care planning, dialysis care, competency of nursing staff, provision of assistive devices, food safety, infection control, and bed safety inspections. Deficiencies were generally of minimal harm and affected few residents.
Deficiencies (10)
F 0585: The facility failed to ensure all resident grievances were thoroughly investigated including pertinent findings for 1 of 39 residents.
F 0641: The facility failed to accurately code the resident's Minimum Data Set for anticoagulant use for 1 of 2 residents reviewed.
F 0656: The facility failed to develop a comprehensive care plan including orders for an AFO brace for 1 of 2 residents investigated for positioning and mobility.
F 0657: The facility failed to revise the care plan to include appropriate fall interventions after a resident fall for 1 of 3 residents investigated for accidents.
F 0698: The facility failed to document daily assessment and monitoring of a resident's dialysis site for 1 resident requiring dialysis.
F 0726: The facility's nursing staff failed to demonstrate competency by failing to assess and report bruises for 1 of 3 residents investigated for skin conditions.
F 0810: The facility failed to provide an assistive eating device at mealtimes for 1 of 5 residents who used such devices.
F 0812: The facility failed to ensure opened refrigerated food items were cleaned and labeled with the date opened before storing, affecting food safety.
F 0880: The facility failed to ensure staff and resident wore appropriate PPE for a resident on contact precautions, allowing the resident to be in therapy gym without PPE.
F 0909: The facility failed to conduct regular inspections of beds for proper mattress fit for the bed's frame for 1 of 3 residents investigated for accidents.
Report Facts
Residents affected: 39
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 115
Residents affected: 115
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nursing | Interviewed regarding grievance investigation and dialysis site monitoring |
| S7LPN | Licensed Practical Nurse | Interviewed regarding grievance investigation and AFO brace order |
| S10PT | Physical Therapist | Interviewed regarding AFO brace order |
| S11LPN | Licensed Practical Nurse | Interviewed regarding AFO brace order |
| S16LPN | Licensed Practical Nurse | Completed incident report and progress note for resident fall |
| S2CORPRN | Corporate Nurse | Confirmed care plan update for fall intervention and bed safety inspection |
| S8LPN | Licensed Practical Nurse | Interviewed regarding bruise assessment and reporting |
| S13LPN | Licensed Practical Nurse | Interviewed regarding assistive eating device provision |
| S3DM | Dietary Manager | Interviewed regarding food service safety and assistive eating devices |
| S14LPN | Licensed Practical Nurse | Interviewed regarding dialysis site assessment documentation |
| S4IP | Infection Preventionist | Interviewed regarding infection control and contact precautions |
| S5IP | Infection Preventionist | Interviewed regarding infection control and contact precautions |
| S6OT | Occupational Therapist | Interviewed regarding therapy for resident on contact precautions |
| S15ADM | Administrator | Interviewed regarding bed mattress and frame incompatibility |
Inspection Report — Jun 18, 2024
Complaint Investigation CMS
Date: Jun 18, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to coordinate hospice care services properly for four residents receiving hospice care, including failure to allow choice of hospice provider, failure to obtain required hospice certifications and plans of care, and failure to notify the hospice agency of an alleged abuse incident.
Complaint Details
The complaint investigation found that the facility did not allow choice of hospice provider, failed to obtain required hospice certifications and plans of care for four residents, and failed to notify the hospice agency of an alleged abuse incident involving Resident #R1. The alleged abuse was substantiated by nurse's notes and interviews.
Findings
The facility failed to coordinate hospice care services for four residents by not allowing choice of hospice provider, not obtaining initial or recertification of terminal illness and hospice plans of care, and failing to notify the hospice agency of an alleged abuse incident involving a resident. Interviews and record reviews confirmed these deficiencies.
Deficiencies (1)
F 0849: The facility failed to allow Residents #1, #2, #3, and #R1 or their responsible parties the choice of hospice provider. The facility also failed to obtain initial certification, recertification of terminal illness, and hospice plans of care for these residents and did not notify the hospice agency of an alleged abuse incident involving Resident #R1.
Report Facts
Residents reviewed for hospice care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3ADON | Assistant Director of Nursing | Confirmed lack of current hospice certifications, recertifications, and plans of care for residents and inability to locate these documents. |
| S2DON | Director of Nursing | Reviewed Resident #R1's EHR and confirmed failure to notify hospice agency of alleged abuse. |
| S1ADM | Administrator | Confirmed facility contracts with two hospice companies and failure to notify hospice agency of alleged abuse incident. |
Inspection Report — Jan 23, 2024
Complaint Investigation CMS
Date: Jan 23, 2024
Visit Reason
The inspection was conducted due to allegations of abuse involving two residents at the facility. The investigation focused on whether staff properly reported and investigated the alleged abuse incidents.
Complaint Details
The complaint investigation involved allegations that Resident #2 pushed a bedside table hitting Resident #1. Staff failed to report the incident immediately to the Director of Nursing and did not conduct a thorough investigation, as the Certified Nursing Assistant witness was not interviewed. The Director of Nursing acknowledged these failures.
Findings
The facility failed to immediately report an incident of alleged abuse involving two residents and did not conduct a thorough investigation, as key staff members were not interviewed. The Director of Nursing confirmed that reporting and investigation procedures were not properly followed.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse to the Administrator or Director of Nursing for two residents involved in an alleged abuse incident.
F 0610: The facility failed to ensure a thorough investigation of an abuse allegation by not interviewing a Certified Nursing Assistant who witnessed the incident.
Report Facts
Residents reviewed for abuse: 4
Residents involved in abuse incident: 2
Date of alleged abuse incident: Jan 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as the person responsible for receiving abuse reports and conducting investigations; failed to interview witness and was unaware of the incident until later. | |
| Certified Nursing Assistant (S3CNA) | Witnessed the abuse incident but did not report it to the Director of Nursing and was not interviewed during the investigation. | |
| Registered Nurse (S2RN) | Informed the Director of Nursing about Resident #2's behavior but did not report the abuse incident; unavailable for interview. |
Inspection Report — Nov 7, 2023
Complaint Investigation CMS
Date: Nov 7, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to accommodate resident needs, ensure nursing staff competencies after unwitnessed falls, and provide pharmaceutical services with proper medication parameters.
Complaint Details
The investigation was complaint-driven, focusing on failure to accommodate resident needs, failure to perform neurological checks after falls, and inadequate pharmaceutical service documentation. The deficiencies were substantiated with observations, interviews, and record reviews.
Findings
The facility failed to ensure call lights were within reach for residents, did not complete required neurological checks after unwitnessed falls for two residents, and lacked specific indicators and parameters for administering Acetaminophen for one resident.
Deficiencies (3)
F 0558: The facility failed to reasonably accommodate resident needs by not ensuring the call light was within reach for Resident #1.
F 0726: The facility failed to ensure nursing staff initiated and completed neurological checks after unwitnessed falls for Residents #1 and #2.
F 0755: The facility failed to provide pharmaceutical services meeting resident needs by lacking specific indicators and parameters for Acetaminophen administration for Resident #3.
Report Facts
Residents sampled: 3
Unwitnessed falls: 3
Unwitnessed falls: 1
Acetaminophen doses administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Interviewed regarding neurological checks and confirmed lack of documentation for falls. |
| S4LPN | Licensed Practical Nurse | Confirmed call light was not in reach for Resident #1. |
| S5LPN | Licensed Practical Nurse | Confirmed lack of parameters for Acetaminophen administration for Resident #3. |
| S1CORPRN | Corporate Registered Nurse | Reviewed Resident #3's records and confirmed medication order issues. |
Inspection Report — Oct 4, 2023
Annual Inspection CMS
Date: Oct 4, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Pelican Pointe Healthcare and Rehabilitation.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident medical record privacy, failure to follow physician orders for splint application, and failure to maintain a clean and homelike environment for residents using wheelchairs.
Deficiencies (3)
F 0583: The facility failed to maintain privacy and confidentiality of residents' medical records. Resident #18's private medical information was visible on an unattended desktop computer screen.
F 0656: The facility failed to develop and implement a complete care plan meeting all resident needs. Resident #59's left wrist and right hand splints were not applied as ordered by the physician.
F 0921: The facility failed to provide a homelike environment by not ensuring Resident #52's wheelchair and wheelchair pad were cleaned, with old food noted on the wheelchair.
Report Facts
Residents affected: 64
Sampled residents: 40
Residents investigated for environment: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Confirmed failure to initiate privacy screen and apply splints | |
| Certified Nursing Assistant | Stated splints were not applied to Resident #59 | |
| Certified Nursing Assistant Supervisor | Confirmed wheelchair cleaning schedule and noted failure to clean Resident #52's wheelchair |
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