Columbine Commons Health and Rehab LLC
Windsor · 1.5 mi · 60 beds
Citations0Substantiated0
Pelican Pointe Health and Rehabilitation Center
710 3RD ST, Windsor, CO, 80550
Nursing home104 licensed beds0 citations on record
1 more within 6 milesOpen in Maps
Has this facility been cited?
Yes. Federal inspectors cited 12 deficiencies against Pelican Pointe Health and Rehabilitation Center in Windsor, Colorado at its most recent standard inspection on 2026-01-15, 6 of them arising from complaints. 1 finding has been recorded at the immediate-jeopardy level, the most serious CMS uses, meaning a resident was placed in immediate danger. Medicare has fined it 4 times, totalling $71,640. CMS currently flags this home for abuse. Medicare rates it 1 out of 5 overall.
1 / 5Medicare overall rating
104certified beds
12deficiencies at the last inspection
1immediate-jeopardy findings on record
3actual-harm findings on record
4federal fines, $71,640
What the inspectors found
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
Immediate jeopardyA resident was placed in immediate danger. The most serious band CMS uses.1
Actual harmA resident was harmed, but not placed in immediate danger.3
Potential for more than minimal harmNo resident was harmed, but the failing could have caused it.39
Potential for minimal harmThe least serious band.0
Most recentGDDDDDDDDJFFDEEEGFFF
The last 20 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · F0684 · 2026-05-19 · from a complaint · Actual harm to a resident
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · F0760 · 2026-05-19 · from a complaint · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2026-05-19 · from a complaint · No actual harm, potential for more than minimal harm
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0605 · 2026-01-15 · standard survey · No actual harm, potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · F0657 · 2026-01-15 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · F0686 · 2026-01-15 · standard survey · No actual harm, potential for more than minimal harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · F0698 · 2026-01-15 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2026-01-15 · standard survey · No actual harm, potential for more than minimal harm
Implement a program that monitors antibiotic use.
Infection Control Deficiencies · F0881 · 2026-01-15 · standard survey · No actual harm, potential for more than minimal harm
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 · F0600 · 2025-07-15 · from a complaint · Immediate jeopardy to resident health or safety
Employ staff that are licensed, certified, or registered in accordance with state laws.
Administration Deficiencies · F0839 · 2025-07-15 · from a complaint · No actual harm, potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · F0867 · 2025-07-15 · from a complaint · No actual harm, potential for more than minimal harm
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 · F0585 · 2025-02-04 · from a complaint · No actual harm, potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · F0677 · 2024-06-10 · from a complaint · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2024-06-10 · from a complaint · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2024-06-10 · from a complaint · No actual harm, potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · F0692 · 2023-12-11 · standard survey · Actual harm to a resident
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 · F0838 · 2023-12-11 · standard survey · No actual harm, potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · F0867 · 2023-12-11 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2023-12-11 · standard survey · No actual harm, potential for more than minimal harm
Medicare’s own rating
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
OverallCombines the three below1 of 5
Health inspectionBased on the last three inspection cycles1 of 5
StaffingNurse hours per resident, adjusted for how sick residents are4 of 5
Quality measuresResident outcomes reported by the home3 of 5
Nurse hours per resident per dayReported by the home to CMS3.32522
Nursing staff turnoverShare of nursing staff who left in a year53.7%
Penalties
What Medicare has fined this home
FinesCivil money penalties imposed by CMS4
Total fined$71,640
Payment denials and other penaltiesMedicare refusing to pay for new admissions is the usual one4
Ownership
Who owns Pelican Pointe Health and Rehabilitation Center
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| CHOHAN, JAMEEL | Individual | NOT APPLICABLE | since 09/01/2024 |
| JORGENSEN, DAVID | Individual | NOT APPLICABLE | since 05/24/2024 |
| BURNAM, SOON | Individual | NOT APPLICABLE | since 05/24/2024 |
| GRAHAM, JOSEPH | Individual | NOT APPLICABLE | since 05/24/2024 |
| JORGENSEN, DAVID | Individual | NOT APPLICABLE | since 05/24/2024 |
| KEETCH, CHAD | Individual | NOT APPLICABLE | since 03/01/2011 |
| SATO, AMI | Individual | NOT APPLICABLE | since 09/09/2024 |
| BURNAM, SOON | Individual | NOT APPLICABLE | since 09/01/2024 |
| CHOHAN, JAMEEL | Individual | NOT APPLICABLE | since 09/01/2024 |
| HRIBAR, KENNETH | Individual | NOT APPLICABLE | since 10/14/2025 |
| ENSIGN SERVICES INC | Organization | NOT APPLICABLE | since 09/01/2024 |
| SMV PROPERTY HOLDINGS LLC | Organization | NOT APPLICABLE | since 09/01/2024 |
Part of the THE ENSIGN GROUP group.
Nearby
Other licensed providers within six miles
Listed by distance. Nobody paid to appear here and the order is not for sale.
Contact
Ask Pelican Pointe Health and Rehabilitation Center a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 065278.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction