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Nursing homeFAID #1358

Pelican Pointe Health and Rehabilitation Center

710 3RD ST, WINDSOR, CO, 80550
(970) 686-7474
ensignservices.net
104 licensed beds
★★★★★1/5CMS Five-Star overall1/5 health inspections4/5 staffing3/5 quality measuresSource: CMS Care Compare

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Photo of PELICAN POINTE HEALTH AND REHABILITATION CENTER
Photo via Google · Thomas Carranza

Public record summary

What we can show you for free.
Bed capacity
104
State license
020332
CMS facility ID
065278
Care type
Nursing home
Facility name
Pelican Pointe Health and Rehabilitation Center
Street address
710 3RD ST
City / state / ZIP
Windsor, CO 80550
Phone
(970) 686-7474
Website
ensignservices.net
State license #
020332

About this facility — Pelican Pointe Health and Rehabilitation Center

Pelican Pointe Health and Rehabilitation Center is a Medicare/Medicaid-certified skilled nursing facility in Windsor, Colorado. It is licensed for 104 beds — above the median for skilled nursing facilities in Colorado (90 beds).

It is one of 6 senior care facilities in Windsor and 210 skilled nursing facilities across Colorado. Families comparing options should weigh inspection history, ownership record, and litigation — not just the tour — before deciding.

Federal inspectors have cited Pelican Pointe Health and Rehabilitation Center 62 times across 12 inspections in the last three years, including 2 food-safety citations, and CMS has imposed $71,640 in fines. Every citation is listed, dated, and graded in the inspection record below.

This listing draws on federal CMS Nursing Home Compare records, and was last updated on August 31, 2026. Background reports are compiled from primary sources — state inspection files, federal CMS data, corporate registrations, and court records — at the time of order.

Facility background

What the public record shows.

Ownership & operator

Parent company
The Ensign Group
Ownership type
For profit - Corporation

Registered owners & officers

Burnam, Soon
Officer · Operational control — since 2024
Chohan, Jameel
Governing body · Operational control · Additional disclosable party — since 2024
Ensign Services Inc
Additional disclosable party — since 2024
Graham, Joseph
Officer — since 2024
Hribar, Kenneth
Operational control · Additional disclosable party — since 2025
Jorgensen, David
Director · Officer — since 2024
Keetch, Chad
Officer — since 2011
Sato, Ami
Officer — since 2024
Smv Property Holdings Llc
Additional disclosable party — since 2024

Regulatory standing

Federal court records
11 naming its parent company — view the cases (a listed case is not a finding of wrongdoing)
License status
Active
Licensed / certified since
1990-06-01
CMS overall rating
1 of 5 stars
Health deficiencies
9 at the last standard inspection
Federal fines
$71,640 total
Last standard inspection
2026-01-15
Nurse staffing
3.3 hours per resident per day

Cost & payer profile (FY2023 cost report)

Average billed charges
$451 per day (≈ $13,710/month). Private-pay prices typically track billed charges; Medicare and Medicaid pay set rates.
Payer mix (resident days)
76% Medicaid · 2% Medicare · 22% private/other
Occupancy
78% (fiscal year 2023)
Vs. state median
11% above the CO median of $407/day — full state cost breakdown

Services & coverage

Licensed beds
104
Licensed as
Nursing Facilities
Medicare
Accepted
Medicaid
Accepted
Wheelchair accessible
entrance and parking
Visiting hours
Daily Open 24 hours
Compiled from CMS Nursing Home Compare; owners/officers from the CMS Ownership dataset; cost & occupancy from the facility's own CMS cost report; hours/accessibility via Google · last verified 2026-08-31. Facilities can submit a correction.

Inspection record

Every citation, dated and graded.

Kitchen & food safety

Federal surveyors inspect the kitchen at every standard visit. This facility has 2 food-safety citations on its three-year record — flagged below among the inspections.
2026-05-19Health inspectionComplaint-triggered3 citations
F-0684
G · Actual harmFrom a complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-06-05
F-0760
D · No harm foundFrom a complaint
Ensure that residents are free from significant medication errors.
Corrected 2026-06-05
F-0880
D · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2026-06-05
2026-01-15Health inspection6 citations
F-0605
D · No harm found
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-07
F-0657
D · No harm found
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-02-07
F-0686
D · No harm found
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-07
F-0698
D · No harm found
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-02-07
F-0880
D · No harm found
Provide and implement an infection prevention and control program.
Corrected 2026-02-07
F-0881
D · No harm found
Implement a program that monitors antibiotic use.
Corrected 2026-02-07
9 earlier / fire-safety inspections (53 citations)
2025-07-15Health inspectionComplaint-triggered3 citations
F-0600
J · Immediate jeopardyFrom a complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-08
F-0839
F · No harm foundFrom a complaint
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-08-08
F-0867
F · No harm foundFrom a complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-08
2025-02-04Health inspectionComplaint-triggered1 citation
F-0585
D · No harm foundFrom a complaint
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.
Corrected 2025-02-19
2024-06-10Health inspectionComplaint-triggered3 citations
F-0677
E · No harm foundFrom a complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-12
F-0689
E · No harm foundFrom a complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-11
F-0880
E · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2024-06-11
2023-12-11Health inspectionComplaint-triggered17 citations
F-0585
D · No harm foundFrom a complaint
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.
Corrected 2023-12-29
F-0600
D · No harm found
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-29
F-0609
D · No harm found
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-29
F-0658
D · No harm found
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-29
F-0660
D · No harm found
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-12-29
F-0692
G · Actual harm
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-29
F-0744
E · No harm found
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-12-29
F-0761
D · No harm found
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.
Corrected 2023-12-29
F-0806
D · No harm foundFood safety
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-12-29
F-0838
F · No harm found
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.
Corrected 2023-12-29
F-0867
F · No harm found
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-29
F-0880
F · No harm found
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
F-0883
F · No harm found
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-29
F-0908
F · No harm found
Keep all essential equipment working safely.
Corrected 2023-12-29
F-0943
F · No harm found
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-12-29
F-0944
F · No harm found
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-12-29
F-0949
F · No harm found
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-12-29
2023-08-07Health inspectionComplaint-triggered2 citations
F-0584
E · No harm foundFrom a complaint
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.
Corrected 2023-08-08
F-0684
D · No harm foundFrom a complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-08
2022-08-25Health inspection8 citations
F-0584
D · No harm found
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.
Corrected 2022-09-28
F-0600
G · Actual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-28
F-0689
D · No harm found
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-28
F-0744
E · No harm found
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-09-28
F-0760
D · No harm found
Ensure that residents are free from significant medication errors.
Corrected 2022-09-28
F-0812
F · No harm foundFood safety
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-28
F-0849
D · No harm found
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.
Corrected 2022-09-28
F-0925
F · No harm found
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-09-28
2026-01-15Fire-safety inspection12 citations
K-0161
F · No harm found
Use approved construction type or materials.
Corrected 2027-02-10
K-0211
E · No harm found
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-03-09
K-0223
E · No harm found
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-03-09
K-0351
F · No harm found
Install an approved automatic sprinkler system.
Corrected 2026-08-10
K-0353
F · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-04-20
K-0374
E · No harm found
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2027-02-10
K-0500
E · No harm found
Meet other general requirements that are deficient.
Corrected 2026-03-11
K-0521
F · No harm found
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K-0741
E · No harm found
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-02-25
K-0918
F · No harm found
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-03-06
K-0923
E · No harm found
Have proper medical gas storage and administration areas.
Corrected 2026-03-10
K-0927
E · No harm found
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2026-03-27
2023-12-11Fire-safety inspection6 citations
E-0004
F · No harm found
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-12-29
E-0029
F · No harm found
Develop a communication plan.
Corrected 2023-12-29
E-0036
F · No harm found
Establish emergency prep training and testing.
Corrected 2023-12-29
E-0037
F · No harm found
Establish staff and initial training requirements.
Corrected 2023-12-29
K-0355
D · No harm found
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-12
K-0914
F · No harm found
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-12
2022-08-25Fire-safety inspection1 citation
K-0521
F · No harm found
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Federal penalties

2025-07-15Fine$28,780
2023-12-11Fine$30,862
2023-11-20Fine$3,529
2023-10-30Fine$8,469
Total fines$71,640
Citations and penalties from the CMS Provider Data Catalog (three-year survey window, refreshed monthly). Severity codes follow the federal scope/severity grid; “Immediate jeopardy” is the most serious grade CMS issues. CCN 065278.

Visitor reviews

What people say on Google.
4.153 ratings on Google
★★★★★Christopher Rowe · 2026-06-26 · via Google

“After 20 months of my family and I caring for my Mother who has severe dementia, we were able to place her in the Memory Care unit at Pelican Pointe. The process was a little bumpy at first, but Reyna and the Staff helped us the whole way and smoothed the transition. In fact, the day we moved her in was seamless because of Reyna and the Staff's efforts. We left Mom there for ten days without co…”

★★★★★Alex Bellford · 2026-05-13 · via Google

“My dad was here not long ago and while we were navigating what rehab would be this facility stood out to us! The residents were out enjoying their day and engaging. Staff greeted and welcomed us and the admissions gal Raina explained everything in depth. The care he received was phenomenal! He is now home and thriving. We got a call today to see how things were going and if we needed anything. The…”

★★★★★Atreya Ashton · 2026-05-18 · via Google

“Pelican pointe went above and beyond for my dad and our family. My dad was out of state in the hospital and was place on palliative care and needed transitioned to hospice care. Their admissions director Reyna went out of her way to call the hospital and transportation agency to align schedules, ensure my dad would be comfortable the entire ride and that my mother could accompany him. They did tha…”

Ratings and reviews are from Google and reflect visitor opinions, not our verification. See all reviews on Google

Inside your report

What unlocks when you order.

Ownership & corporate history

Primary tier
Prior operators & transfers
Corporate network & affiliates
,
Owners' other facilities
· · 2 more

Inspection citations — last 5 years

Locked
The 62 citations above are shown free. The report takes each one and explains it in plain English — what the tag requires, how serious the scope/severity grade really is, whether it recurred across surveys — plus the five-year pattern a single inspection can't show.

Civil & criminal lawsuits

Advanced tier only
Active civil suits
#
Federal dockets
CDC infection data
Unlock the full file
Citations, owner history, lawsuits — decoded into one PDF.
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Original records

Sources we pull for this facility.
Source
CMS Nursing Home Compare
data.cms.gov Provider Data Catalog
Last verified 2026-08-31
Source
Google Business Profile
Photos, reviews & hours
Displayed with attribution · refreshed on re-run
Source
Secretary of State filings
Entity & officer search
Pulled when a report is ordered
Source
PACER federal dockets
pacer.uscourts.gov
Pulled when a report is ordered