Nursing homeActive
Pelican Pointe Health And Rehabilitation Center
710 3rd St, Windsor, CO 805509706867474104 certified beds · 86 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
8
since 2022
Deficiencies
43
● 0● 39● 4
Penalties · 3 yrs
$71,640
4 fines
Last survey
2026-05-19
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 4
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Colorado Department of Public Health & Environment · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-05-19 | Complaint | 021 | CMS-2567 (Care Compare) | — |
| 2026-01-15 | Standard | 060 | CMS-2567 (Care Compare) | — |
| 2025-07-15 | Complaint | 021 | CMS-2567 (Care Compare) | — |
| 2025-02-04 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-06-10 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2023-12-11 | Standard | 0161 | CMS-2567 (Care Compare) | — |
| 2023-08-07 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2022-08-25 | Standard | 071 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Colorado Department of Public Health & Environment publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-06-05Record 065278-20260519-F684
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 065278-20260519-F760
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 065278-20260519-F880
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-07Record 065278-20260115-F605
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-07Record 065278-20260115-F657
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-07Record 065278-20260115-F686
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-07Record 065278-20260115-F698
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-07Record 065278-20260115-F880
F881Implement a program that monitors antibiotic use.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-07Record 065278-20260115-F881
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-08-08Record 065278-20250715-F600
F839Employ staff that are licensed, certified, or registered in accordance with state laws.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-08-08Record 065278-20250715-F839
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-08-08Record 065278-20250715-F867
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-19Record 065278-20250204-F585
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-12Record 065278-20240610-F677
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-11Record 065278-20240610-F689
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-11Record 065278-20240610-F880
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-12-29Record 065278-20231211-F692
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F585
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F609
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F658
F660Plan the resident's discharge to meet the resident's goals and needs.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F660
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F744
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F761
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F806
F838Conduct 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.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F838
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F867
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F883
F908Keep all essential equipment working safely.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F908
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Scope/severity FStandard
Abuse & neglect
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F943
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F944
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-29Record 065278-20231211-F949
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-08Record 065278-20230807-F584
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-08Record 065278-20230807-F684
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-09-28Record 065278-20220825-F600
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-28Record 065278-20220825-F584
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-28Record 065278-20220825-F689
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-09-28Record 065278-20220825-F744
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-28Record 065278-20220825-F760
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-09-28Record 065278-20220825-F812
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-28Record 065278-20220825-F849
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-09-28Record 065278-20220825-F925
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-07-15 | Civil money penalty | $28,780 | CMS · Penalties |
| 2023-12-11 | Civil money penalty | $30,862 | CMS · Penalties |
| 2023-11-20 | Civil money penalty | $3,529 | CMS · Penalties |
| 2023-10-30 | Civil money penalty | $8,469 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.84
Facility
Colorado
National
Colorado 0.82 · National 0.69
Total nurse hours per resident day3.33
Facility
Colorado
National
Colorado 3.72 · National 3.86
Weekend total nurse hours2.97
Facility
Colorado
National
Colorado 3.30 · National 3.42
Total nursing staff turnover54%
Facility
Colorado
National
Colorado 47% · National 46%
Registered nurse turnover32%
Facility
Colorado
National
Colorado 45% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Colorado | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 4.8% | 3.4% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 4.9% | 3.4% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 38.9% | 20.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.6% | 1.4% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 10.2% | 13.4% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 8.6% | 4.7% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 5.9% | 11.5% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Burnam, Soon Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Chohan, Jameel Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Hribar, Kenneth Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Burnam, Soon Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Chohan, Jameel Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Chohan, Jameel Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Ensign Services Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Graham, Joseph Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Hribar, Kenneth Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Jorgensen, David Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Jorgensen, David Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Keetch, Chad Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Sato, Ami Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Smv Property Holdings LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
The Ensign Group — 342 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Colorado.
No county cost figures on file for Weld.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Columbine Commons Health And Rehab LLC Windsor | 1.6 mi | 2025-04-17 | 060 |
| Grace Pointe Cont Care Sr Campus, Skilled Nursing Greeley | 7.3 mi | 2026-02-26 | 041 |
| Center At Centerplace, LLC, The Greeley | 8.6 mi | 2026-04-22 | 0152 |
| Life Care Center Of Greeley Greeley | 9.0 mi | 2024-07-16 | 022 |
| Lemay Avenue Health And Rehab LLC Fort Collins | 9.0 mi | 2026-06-01 | 071 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |