Pelican Pointe Health and Rehabilitation Center

CMS star ratings

Overall★★★★★ 1/5

State avg 3.1

Health inspections★★★★★ 1/5

State avg 2.7

Staffing★★★★★ 4/5

State avg 3.1

Quality measures★★★★★ 3/5

State avg 4.1

Long-stay quality★★★★★ 3/5

Short-stay qualityNot rated

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing: 3.33 (state 3.72 · U.S. 3.86)
Registered nurses (RN): 0.84 (state 0.82 · U.S. 0.69)
Licensed practical nurses: 0.36 (state 0.68 · U.S. 0.86)
Nurse aides: 2.12 (state 2.22 · U.S. 2.32)
Weekend total: 2.97 (state 3.30 · U.S. 3.42)
Nursing staff turnover: 53.7 (state 47.1 · U.S. 45.8)%
RN turnover: 31.6 (state 44.6 · U.S. 42.9)%
Administrators who left: 1 in the last year

Inspections

Last standard inspection: January 15, 2026
Health deficiencies (last cycle): 9.0 (state 8.6 · U.S. 9.3)
From complaints: 3
Citations on record (3 years): 43 health · 19 fire safety · includes immediate jeopardy

Date	Citation	Severity	Status
2026-05-19	Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection	G Actual harm	Corrected 2026-06-05
2026-05-19	Ensure that residents are free from significant medication errors. F0760 · Pharmacy Service Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2026-06-05
2026-05-19	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	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. F0605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	D No actual harm, potential for more than minimal harm	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. F0657 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2026-02-07
2026-01-15	Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2026-02-07
2026-01-15	Provide safe, appropriate dialysis care/services for a resident who requires such services. F0698 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2026-02-07
2026-01-15	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2026-02-07
2026-01-15	Implement a program that monitors antibiotic use. F0881 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection	J Immediate jeopardy to resident health or safety	Corrected 2025-08-08
2025-07-15	Employ staff that are licensed, certified, or registered in accordance with state laws. F0839 · Administration Deficiencies · complaint inspection	F No actual harm, potential for more than minimal harm	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. F0867 · Administration Deficiencies · complaint inspection	F No actual harm, potential for more than minimal harm	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. F0585 · Resident Rights Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2025-02-19
2024-06-10	Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies · complaint inspection	E No actual harm, potential for more than minimal harm	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. F0689 · Quality of Life and Care Deficiencies · complaint inspection	E No actual harm, potential for more than minimal harm	Corrected 2024-06-11
2024-06-10	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection	E No actual harm, potential for more than minimal harm	Corrected 2024-06-11
2023-12-11	Provide enough food/fluids to maintain a resident's health. F0692 · Quality of Life and Care Deficiencies	G Actual harm	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. F0838 · Administration Deficiencies	F No actual harm, potential for more than minimal harm	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. F0867 · Administration Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883 · Infection Control Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Keep all essential equipment working safely. F0908 · Environmental Deficiencies	F No actual harm, potential for more than minimal harm	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. F0943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. F0944 · Administration Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Provide behavior health training consistent with the requirements and as determined by a facility assessment. F0949 · Administration Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. F0744 · Quality of Life and Care Deficiencies	E No actual harm, potential for more than minimal harm	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. F0585 · Resident Rights Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Ensure services provided by the nursing facility meet professional standards of quality. F0658 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-12-29
2023-12-11	Plan the resident's discharge to meet the resident's goals and needs. F0660 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	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. F0806 · Nutrition and Dietary Deficiencies	D No actual harm, potential for more than minimal harm	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. F0584 · Resident Rights Deficiencies · complaint inspection	E No actual harm, potential for more than minimal harm	Corrected 2023-08-08
2023-08-07	Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2023-08-08
2022-08-25	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	G Actual harm	Corrected 2022-09-28
2022-08-25	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2022-09-28
2022-08-25	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. F0925 · Environmental Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2022-09-28
2022-08-25	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. F0744 · Quality of Life and Care Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2022-09-28
2022-08-25	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. F0584 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2022-09-28
2022-08-25	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2022-09-28
2022-08-25	Ensure that residents are free from significant medication errors. F0760 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2022-09-28
2022-08-25	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. F0849 · Administration Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2022-09-28

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

4 penalties in the last three years, including $71,640 in fines.

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

Ownership & management

Name	Role	Since
Chohan, Jameel (individual)	Administrator · NOT APPLICABLE
Ensign Services INC (organization)	Administrator · NOT APPLICABLE
Hribar, Kenneth (individual)	Administrator · NOT APPLICABLE
SMV Property Holdings LLC (organization)	Administrator · NOT APPLICABLE
Jorgensen, David (individual)	Corporate Director · NOT APPLICABLE
Burnam, Soon (individual)	Corporate Officer · NOT APPLICABLE
Graham, Joseph (individual)	Corporate Officer · NOT APPLICABLE
Jorgensen, David (individual)	Corporate Officer · NOT APPLICABLE
Keetch, Chad (individual)	Corporate Officer · NOT APPLICABLE
Sato, Ami (individual)	Corporate Officer · NOT APPLICABLE
Chohan, Jameel (individual)	Managing Control - Governing Body · NOT APPLICABLE
Burnam, Soon (individual)	Operational/managerial Control · NOT APPLICABLE
Chohan, Jameel (individual)	Operational/managerial Control · NOT APPLICABLE
Hribar, Kenneth (individual)	Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Pelican Pointe Health and Rehabilitation Center?

Pelican Pointe Health and Rehabilitation Center has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.1-star average in Colorado.

How many beds does Pelican Pointe Health and Rehabilitation Center have?

It has 104 certified beds and cares for about 86 residents per day.

Has Pelican Pointe Health and Rehabilitation Center been fined?

Yes. CMS lists 4 penalties totaling $71,640 in the last three years.

Who owns Pelican Pointe Health and Rehabilitation Center?

It is part of The Ensign Group and is classified as for profit - corporation. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Pelican Pointe Health and Rehabilitation Center?

(970) 686-7474. The facility is located at 710 3RD ST, Windsor, CO 80550.

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Contact & location

Facility details