F60

PELICAN POINTE HEALTH AND REHABILITATION CENTER

Grade F 60/100 composite score

For profit - CorporationSFF CandidateAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

104

Ownership

For profit - Corporation

Total Fines

$42,860

Last Survey

N/A

710 3RD ST, WINDSOR, CO 80550
9706867474

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.95h
LPN
0.55h
CNA
2.92h
Total
4.42h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

ENDURA HEALTHCARE LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2024

100%

THE ENSIGN GROUP INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2024

100%

FUENTEZ, JOSEPH

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2024

JORGENSEN, DAVID

IndividualCORPORATE DIRECTORSince May 2024

BURNAM, SOON

IndividualCORPORATE OFFICERSince May 2024

GRAHAM, JOSEPH

IndividualCORPORATE OFFICERSince May 2024

JORGENSEN, DAVID

IndividualCORPORATE OFFICERSince May 2024

SATO, AMI

IndividualCORPORATE OFFICERSince Sep 2024

Penalties & Fines (3)

$42,860total fines
DateTypeDescriptionAmount
Dec 11, 2023Fine$30,862
Nov 20, 2023Fine$3,529
Oct 30, 2023Fine$8,469

Health Inspection Deficiencies (47)

July 15, 2025Health3 deficiencies1 severe
0600JImmediate jeopardy, Isolated

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

Corrected Aug 8, 2025
0839FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Aug 8, 2025
0867FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Aug 8, 2025
February 4, 2025Health1 deficiency
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Feb 19, 2025
June 10, 2024Health3 deficiencies
0677EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Jun 12, 2024
0689EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Jun 11, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jun 11, 2024
December 11, 2023Health17 deficiencies1 severe
0600DMinimal harm, Isolated

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

Corrected Dec 29, 2023
0609DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 29, 2023
0658DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 29, 2023
0660DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 29, 2023
0692GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Dec 29, 2023
0744EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Dec 29, 2023
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Dec 29, 2023
0806DMinimal harm, Isolated

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

Nutrition and Dietary Deficiencies

Corrected Dec 29, 2023
0838FMinimal harm, Widespread

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

Corrected Dec 29, 2023
0867FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Dec 29, 2023
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 29, 2023
0883FMinimal harm, Widespread

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

Infection Control Deficiencies

Corrected Dec 29, 2023
0908FMinimal harm, Widespread

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Dec 29, 2023
0943FMinimal harm, Widespread

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 29, 2023
0944FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Dec 29, 2023
0949FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Dec 29, 2023
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Dec 29, 2023
August 7, 2023Health2 deficiencies
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Aug 8, 2023
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Aug 8, 2023
August 25, 2022Health8 deficiencies1 severe
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Sep 28, 2022
0600GActual harm, Isolated

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

Corrected Sep 28, 2022
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0744EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Sep 28, 2022
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Sep 28, 2022
0849DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Sep 28, 2022
0925FMinimal harm, Widespread

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

Environmental Deficiencies

Corrected Sep 28, 2022
June 15, 2021Health13 deficiencies1 severe
0550GActual harm, Isolated

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

Resident Rights Deficiencies

Corrected Jul 22, 2021
0565EMinimal harm, Pattern

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

Resident Rights Deficiencies

Corrected Jul 22, 2021
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Jul 22, 2021
0600EMinimal harm, Pattern

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

Corrected Jul 22, 2021
0603DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 22, 2021
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jul 22, 2021
0697DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jul 22, 2021
0725EMinimal harm, Pattern

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

Nursing and Physician Services Deficiencies

Corrected Jul 22, 2021
0744EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Jul 22, 2021
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Jul 22, 2021
0804EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Jul 22, 2021
0814FMinimal harm, Widespread

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Jul 22, 2021
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jul 22, 2021

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Frequently Asked Questions

What is the CareGrader rating for PELICAN POINTE HEALTH AND REHABILITATION CENTER?

PELICAN POINTE HEALTH AND REHABILITATION CENTER in WINDSOR, Colorado has a CareGrader grade of F (Poor), with a composite score of 59.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for PELICAN POINTE HEALTH AND REHABILITATION CENTER?

PELICAN POINTE HEALTH AND REHABILITATION CENTER has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does PELICAN POINTE HEALTH AND REHABILITATION CENTER have?

PELICAN POINTE HEALTH AND REHABILITATION CENTER has 47 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has PELICAN POINTE HEALTH AND REHABILITATION CENTER been fined?

Yes. PELICAN POINTE HEALTH AND REHABILITATION CENTER has $42,860 in total fines from CMS enforcement actions across 3 penalties.

How many beds does PELICAN POINTE HEALTH AND REHABILITATION CENTER have?

PELICAN POINTE HEALTH AND REHABILITATION CENTER has 104 certified beds with approximately 82 current residents (79% occupancy). The facility is located at 710 3RD ST, WINDSOR, Colorado 80550. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.