Nursing homes › Colorado › Pelican Pointe Health and Rehabilitation Center
710 3Rd St, Windsor, CO 80550 · 9706867474 · 104 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 3.33 (Colorado median: 3.49). RN hours: 0.84. Weekend total: 2.97. Nursing staff turnover: 54%.
All-time on record: 43 deficiency citations, including 1 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-05-19 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | complaint | corrected 2026-06-05 |
| 2026-05-19 | Ensure that residents are free from significant medication errors. | D | complaint | corrected 2026-06-05 |
| 2026-05-19 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2026-06-05 |
| 2026-01-15 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D | Health | corrected 2026-02-07 |
| 2026-01-15 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Health | corrected 2026-02-07 |
| 2026-01-15 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Health | corrected 2026-02-07 |
| 2026-01-15 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Health | corrected 2026-02-07 |
| 2026-01-15 | Provide and implement an infection prevention and control program. | D | Health | corrected 2026-02-07 |
| 2026-01-15 | Implement a program that monitors antibiotic use. | D | Health | corrected 2026-02-07 |
| 2025-07-15 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | complaint | corrected 2025-08-08 |
| 2025-07-15 | Employ staff that are licensed, certified, or registered in accordance with state laws. | F | complaint | corrected 2025-08-08 |
| 2025-07-15 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | complaint | corrected 2025-08-08 |
| 2025-02-04 | 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. | D | complaint | corrected 2025-02-19 |
| 2024-06-10 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | complaint | corrected 2024-06-12 |
| 2024-06-10 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | complaint | corrected 2024-06-11 |
| 2024-06-10 | Provide and implement an infection prevention and control program. | E | complaint | corrected 2024-06-11 |
| 2023-12-11 | Provide enough food/fluids to maintain a resident's health. | G | Health | corrected 2023-12-29 |
| 2023-12-11 | 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. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Provide and implement an infection prevention and control program. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Keep all essential equipment working safely. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | F | Health | corrected 2023-12-29 |
| 2023-12-11 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E | Health | corrected 2023-12-29 |
| 2023-12-11 | 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. | D | complaint | corrected 2023-12-29 |
| 2023-12-11 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Health | corrected 2023-12-29 |
| 2023-12-11 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Health | corrected 2023-12-29 |
| 2023-12-11 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Health | corrected 2023-12-29 |
| 2023-12-11 | Plan the resident's discharge to meet the resident's goals and needs. | D | Health | corrected 2023-12-29 |
| 2023-12-11 | 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. | D | Health | corrected 2023-12-29 |
| 2023-12-11 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Health | corrected 2023-12-29 |
| 2023-08-07 | 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. | E | complaint | corrected 2023-08-08 |
| 2023-08-07 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2023-08-08 |
| Date | Type | Amount |
|---|---|---|
| 2025-07-15 | Fine | $28,780 |
| 2023-12-11 | Fine | $30,862 |
| 2023-11-20 | Fine | $3,529 |
| 2023-10-30 | Fine | $8,469 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| CHOHAN, JAMEEL | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 09/01/2024 |
| JORGENSEN, DAVID | Corporate Director | Individual | NOT APPLICABLE | since 05/24/2024 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 05/24/2024 |
| GRAHAM, JOSEPH | Corporate Officer | Individual | NOT APPLICABLE | since 05/24/2024 |
| JORGENSEN, DAVID | Corporate Officer | Individual | NOT APPLICABLE | since 05/24/2024 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| SATO, AMI | Corporate Officer | Individual | NOT APPLICABLE | since 09/09/2024 |
| BURNAM, SOON | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/01/2024 |
| CHOHAN, JAMEEL | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/01/2024 |
| HRIBAR, KENNETH | Operational/Managerial Control | Individual | NOT APPLICABLE | since 10/14/2025 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 065278. Corrections: data@carerecords.org.