PELICAN POINTE HEALTH AND REHABILITATION CENTER

WINDSOR, CO · 104 beds · For profit - Corporation

0 Trust Score
Grade: F CRITICAL Risk → Stable

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

★☆☆☆☆
CMS Overall
★☆☆☆☆
Health Inspection
21
2.3x state avg
Deficiencies
$42,860
Fines (3-yr)
★★★★☆
Staffing

Violation Timeline

July 14, 2025

3 deficiencyies
F0600 Immediate Jeopardy Scope/Severity: J

Freedom 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.

F0839 Potential Harm Scope/Severity: F

Administration Deficiencies

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Employ staff that are licensed, certified, or registered in accordance with state laws.

F0867 Potential Harm Scope/Severity: F

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 deficiency
F0585 Potential Harm Scope/Severity: D

Resident 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 deficiencyies
F0677 Potential Harm Scope/Severity: E

Quality 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.

F0689 Potential Harm Scope/Severity: E

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.

F0880 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

December 10, 2023

13 deficiencyies
F0600 Potential Harm Scope/Severity: D

Freedom 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.

F0609 Potential Harm Scope/Severity: D

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.

F0658 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

F0660 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

F0692 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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

F0744 Potential Harm Scope/Severity: E

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.

F0761 Potential Harm Scope/Severity: D

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.

F0806 Potential Harm Scope/Severity: D

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.

F0838 Potential Harm Scope/Severity: F

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.

F0867 Potential Harm Scope/Severity: F

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.

F0880 Potential Harm Scope/Severity: F

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0883 Potential Harm Scope/Severity: F

Infection Control Deficiencies

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

F0908 Potential Harm Scope/Severity: F

Environmental Deficiencies

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Keep all essential equipment working safely.

See full violation history →

Staffing

0.95
RN hrs/res/day
0.55
LPN hrs/res/day
2.92
CNA hrs/res/day
3.93
Weekend hrs/res/day
58%
Total nurse turnover
44%
RN turnover

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
Total $42,860

Ownership

For profit - Corporation Chain: THE ENSIGN GROUP
  • 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

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