• CMS rates this facility 1/5 stars (below average)
• Has 104 certified beds with an average of 82.8 residents per day (80% occupancy)
• Last health inspection found 21 deficiencies (inspected Dec 11, 2023)
• Has been fined a total of $42,860 across 3 fine(s)
• Total nursing staff: 3.84 hours per resident per day
• Staff turnover rate: 57.9% (high)
• Part of the The Ensign Group chain (324 facilities)
Pelican Pointe Health and Rehabilitation Center is a 1-star Medicare and Medicaid certified nursing home in Windsor, Colorado with 104 certified beds. It has been operating since 1990. The facility scored below average compared to Colorado facilities.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
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.
Provide enough food/fluids to maintain a resident's health.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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.
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.
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.
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.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Ensure that residents are free from significant medication errors.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
+ 17 more deficiencies
Staffing hours per resident per day. The black line shows the national average.
Quality measures as percentages of residents. Lower is better for all measures.
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| ENDURA HEALTHCARE LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | May 24, 2024 |
| THE ENSIGN GROUP INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | 100% | May 24, 2024 |
| FUENTEZ, JOSEPH | OPERATIONAL/MANAGERIAL CONTROL | Individual | N/A | Sep 1, 2024 |
| JORGENSEN, DAVID | CORPORATE DIRECTOR | Individual | N/A | May 24, 2024 |
| BURNAM, SOON | CORPORATE OFFICER | Individual | N/A | May 24, 2024 |
| GRAHAM, JOSEPH | CORPORATE OFFICER | Individual | N/A | May 24, 2024 |
| JORGENSEN, DAVID | CORPORATE OFFICER | Individual | N/A | May 24, 2024 |
| SATO, AMI | CORPORATE OFFICER | Individual | N/A | Sep 9, 2024 |
This chain operates 324 facilities. View all →