PELICAN POINTE HEALTH AND REHABILITATION CENTER
PELICAN POINTE HEALTH AND REHABILITATION CENTER is a 104-bed nursing home in WINDSOR, Colorado. CMS has certified it for Medicare and Medicaid since 1990-06-01. It averages 85.5 residents a day.
What harm was found in the violations cited at PELICAN POINTE HEALTH AND REHABILITATION CENTER?
CMS lists 43 health-inspection deficiencies for PELICAN POINTE HEALTH AND REHABILITATION CENTER since 2022-08-25, 35 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is J; the most recent health inspection was 2026-05-19.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-05-19 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G |
| 2026-05-19 | F0760, F0880 | Ensure that residents are free from significant medication errors. / Provide and implement an infection prevention and control program. | D |
| 2026-01-15 | F0605, F0657, F0686, F0698, F0880, F0881 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use. | D |
| 2025-07-15 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J |
| 2025-07-15 | F0839, F0867 | Employ staff that are licensed, certified, or registered in accordance with state laws. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F |
| 2025-02-04 | F0585 | 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 |
| 2024-06-10 | F0677, F0689, F0880 | Provide care and assistance to perform activities of daily living for any resident who is unable. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide and implement an infection prevention and control program. | E |
| 2023-12-11 | F0692 | Provide enough food/fluids to maintain a resident's health. | G |
| 2023-12-11 | F0838, F0867, F0880, F0883, F0908, F0943, F0944, F0949 | 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. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. / Provide and implement an infection prevention and control program. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / Keep all essential equipment working safely. / Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. / Provide behavior health training consistent with the requirements and as determined by a facility assessment. | F |
| 2023-12-11 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E |
| 2023-12-11 | F0585, F0600, F0609, F0658, F0660, F0761, F0806 | 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. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Ensure services provided by the nursing facility meet professional standards of quality. / Plan the resident's discharge to meet the resident's goals and needs. / 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. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D |
| 2023-08-07 | F0584 | 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 |
| 2023-08-07 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2022-08-25 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G |
| 2022-08-25 | F0812, F0925 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F |
| 2022-08-25 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E |
| 2022-08-25 | F0584, F0689, F0760, F0849 | 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Ensure that residents are free from significant medication errors. / 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. | D |
Why was PELICAN POINTE HEALTH AND REHABILITATION CENTER fined 4 times?
| 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 |
How is PELICAN POINTE HEALTH AND REHABILITATION CENTER staffed relative to the CO average?
| Measure | This facility | CO average |
|---|---|---|
| Total nurse staffing hours per resident per day | 3.32522 | 3.72368 |
| Total nursing staff turnover (%) | 53.7 | 47.1 |
| Average number of residents per day | 85.5 | 74.8 |
Who owns PELICAN POINTE HEALTH AND REHABILITATION CENTER, and what chain is it in?
PELICAN POINTE HEALTH AND REHABILITATION CENTER is registered with CMS as For profit - Corporation, operates under the legal business name BELMONT RIDGE HEALTHCARE INC and belongs to the THE ENSIGN GROUP chain.
| Role | Owner | Association date |
|---|---|---|
| MANAGING CONTROL - GOVERNING BODY | CHOHAN, JAMEEL | since 09/01/2024 |
| CORPORATE DIRECTOR | JORGENSEN, DAVID | since 05/24/2024 |
| CORPORATE OFFICER | BURNAM, SOON, GRAHAM, JOSEPH, JORGENSEN, DAVID, KEETCH, CHAD, SATO, AMI | since 03/01/2011 |
| OPERATIONAL/MANAGERIAL CONTROL | BURNAM, SOON, CHOHAN, JAMEEL, HRIBAR, KENNETH | since 09/01/2024 |
| ADP OF THE SNF | ENSIGN SERVICES INC, SMV PROPERTY HOLDINGS LLC, CHOHAN, JAMEEL, HRIBAR, KENNETH | since 09/01/2024 |
Were you or a family member harmed at PELICAN POINTE HEALTH AND REHABILITATION CENTER?