01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-15 | 9 | 2026-01-15 | 12 |
| Cycle 2 | 2023-12-11 | 21 | 2023-12-11 | 6 |
| Cycle 3 | 2022-08-25 | 13 | 2022-08-25 | 1 |
CMS CCN 0652782026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Pelican Pointe Health And Rehabilitation Center
710 3Rd St · Windsor, CO 80550 · Weld County
Certified beds104CMS provider file
Recent citation rows62current CMS citation release
Penalty rows4current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
62 rows in the current release
4 rows carry G–L scope/severity codes; 1 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-19 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-06-05 · complaint2026-05-19 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2026-06-05 · complaint2026-05-19 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-06-05 · complaint2026-01-15 · HEALTHF0605Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has date of correction · 2026-02-072026-01-15 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2026-02-072026-01-15 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-02-072026-01-15 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-02-072026-01-15 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-02-072026-01-15 · HEALTHF0881Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2026-02-072026-01-15 · FIREK0161Severity F · widespread; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: No revisit needed · 2027-02-102026-01-15 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2026-03-092026-01-15 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2026-03-092026-01-15 · FIREK0351Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: No revisit needed · 2026-08-102026-01-15 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-01-15 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: No revisit needed · 2027-02-102026-01-15 · FIREK0500Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Meet other general requirements that are deficient.
Correction field: Deficient, Provider has date of correction · 2026-03-112026-01-15 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: No revisit needed2026-01-15 · FIREK0741Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2026-02-252026-01-15 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2026-03-062026-01-15 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2026-03-102026-01-15 · FIREK0927Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Correction field: Deficient, Provider has date of correction · 2026-03-272025-07-15 · HEALTHF0600Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-08-08 · complaint2025-07-15 · HEALTHF0839Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Correction field: Deficient, Provider has date of correction · 2025-08-08 · complaint2025-07-15 · HEALTHF0867Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2025-08-08 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-07-15 | Fine | $28,780 | 0 |
| 2023-12-11 | Fine | $30,862 | 0 |
| 2023-11-20 | Fine | $3,529 | 0 |
| 2023-10-30 | Fine | $8,469 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHOHAN, JAMEELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/01/2024
- JORGENSEN, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/24/2024
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/24/2024
- GRAHAM, JOSEPHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/24/2024
- JORGENSEN, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/24/2024
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- SATO, AMIIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/09/2024
- BURNAM, SOONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- CHOHAN, JAMEELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- HRIBAR, KENNETHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/14/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- SMV PROPERTY HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- CHOHAN, JAMEELIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- HRIBAR, KENNETHIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/14/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.33per resident day
RN hours0.84per resident day
Weekend nurse hours2.97per resident day
Staff turnover53.7%CMS reported field
06 / LOCAL RECORDS
Open the Windsor ledger →