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🔎 Pelican Pointe Health And Rehabilitation Center

Inspection Results


Inspection Overview

Pelican Pointe Health And Rehabilitation Center has been cited for a total of 54 deficiencies since we began saving each survey.

In Colorado, the average facility has **29.64 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

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.

Survey Date: 2025-02-04
Correction Date: 2025-02-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-06-10
Correction Date: 2024-06-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-06-10
Correction Date: 2024-06-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-06-10
Correction Date: 2024-06-11
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Keep all essential equipment working safely.

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-12-11
Correction Date: 2023-12-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-08-07
Correction Date: 2023-08-08
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-08-07
Correction Date: 2023-08-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2022-08-25
Correction Date: 2022-09-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2022-02-22
Correction Date: 2022-03-22
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-02-22
Correction Date: 2022-04-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-02-22
Correction Date: 2022-03-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-02-22
Correction Date: 2022-03-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-02-22
Correction Date: 2022-03-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-02-22
Correction Date: 2022-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-02-22
Correction Date: 2022-03-19
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: G

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Dispose of garbage and refuse properly.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2021-06-15
Correction Date: 2021-07-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-14
Correction Date: 2021-01-15
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide care by qualified persons according to each resident's written plan of care.

Survey Date: 2019-06-03
Correction Date: 2019-06-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2019-06-03
Correction Date: 2019-06-18
Category: Quality of Life and Care Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**