PELICAN POINTE HEALTH AND REHABILITATION CENTER
WINDSOR, CO · 104 beds · For profit - Corporation
Red Flags
- ⚠ This facility has a substantiated finding of abuse
- ⚠ No standard inspection in over 2 years
- ⚠ 1-star health inspection rating (lowest possible)
- ⚠ 21 deficiencies — 2.3x the state average
- ⚠ 1 citation(s) at the highest severity level — immediate risk to residents
- ⚠ 3 citation(s) where residents suffered actual harm
Green Flags
- ✓ 4-star staffing rating
Quick Facts
Violation Timeline
July 14, 2025
3 deficiencyiesFreedom from Abuse, Neglect, and Exploitation Deficiencies
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Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Administration Deficiencies
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Employ staff that are licensed, certified, or registered in accordance with state laws.
Administration Deficiencies
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Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
February 3, 2025
1 deficiencyResident Rights Deficiencies
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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.
June 9, 2024
3 deficiencyiesQuality of Life and Care Deficiencies
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Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
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Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Infection Control Deficiencies
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Provide and implement an infection prevention and control program.
December 10, 2023
13 deficiencyiesFreedom from Abuse, Neglect, and Exploitation Deficiencies
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Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
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Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
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Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies
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Plan the resident's discharge to meet the resident's goals and needs.
Quality of Life and Care Deficiencies
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Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
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Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Pharmacy Service Deficiencies
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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.
Nutrition and Dietary Deficiencies
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Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Administration Deficiencies
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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.
Administration Deficiencies
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Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Infection Control Deficiencies
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Provide and implement an infection prevention and control program.
Infection Control Deficiencies
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Develop and implement policies and procedures for flu and pneumonia vaccinations.
Environmental Deficiencies
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Keep all essential equipment working safely.
Staffing
A nurse checks on each resident roughly every 5.4 hours on average.
Fines & Penalties
- Fine Dec 10, 2023$30,862
- Fine Nov 19, 2023$3,529
- Fine Oct 29, 2023$8,469
Ownership
-
ENDURA HEALTHCARE LLC
5% OR GREATER DIRECT OWNERSHIP INTEREST
Since since 05/24/2024
100% Organization -
THE ENSIGN GROUP INC
5% OR GREATER INDIRECT OWNERSHIP INTEREST
Since since 05/24/2024
100% Organization -
FUENTEZ, JOSEPH
OPERATIONAL/MANAGERIAL CONTROL
Since since 09/01/2024
Individual -
JORGENSEN, DAVID
CORPORATE DIRECTOR
Since since 05/24/2024
Individual -
BURNAM, SOON
CORPORATE OFFICER
Since since 05/24/2024
Individual -
GRAHAM, JOSEPH
CORPORATE OFFICER
Since since 05/24/2024
Individual -
JORGENSEN, DAVID
CORPORATE OFFICER
Since since 05/24/2024
Individual -
SATO, AMI
CORPORATE OFFICER
Since since 09/09/2024
Individual