Federal inspection record · CMS data as of October 1, 2026
Pelican Pointe Health And Rehabilitation Center
710 3rd St, Windsor, CO · (970) 686-7474
- Certified beds
- 104
- Residents per day
- 89
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 1, 1990
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Colorado homes
Pelican Pointe Health And Rehabilitation Center carries 122.75 inspection points. That is fewer than 12% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
42 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (4)
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Provide enough food/fluids to maintain a resident's health.
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G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Quality of Life and Care7E
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Administration7F
- F
Employ staff that are licensed, certified, or registered in accordance with state laws.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
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.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- F
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- D
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.
Infection Control6F
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Implement a program that monitors antibiotic use.
- E
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- F
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Freedom from Abuse, Neglect, and Exploitation5F
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Pharmacy Service3D
- D
Ensure that residents are free from significant medication errors.
- D
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.
- D
Ensure that residents are free from significant medication errors.
Resident Assessment and Care Planning3D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Resident Rights3D
- D
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.
- D
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.
- D
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.
Environmental2F
- F
Keep all essential equipment working safely.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Nutrition and Dietary2F
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspection history
2026-01-15
10 health deficiencies · 12 fire-safety deficiencies
Top issue: Infection Control (3 deficiencies)
2023-12-11
21 health deficiencies · 6 fire-safety deficiencies
Top issue: Administration (6 deficiencies)
2022-08-25
11 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 22 min of nursing staff time a day, 47 min of it from a registered nurse.
This home
3 h 22 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 63% of nursing staff and 35% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$78,577 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-05-19 | Fine | $17,010 |
| 2025-07-15 | Fine | $18,707 |
| 2023-12-11 | Fine | $30,862 |
| 2023-11-20 | Fine | $3,529 |
| 2023-10-30 | Fine | $8,469 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.6 pts better | 0.8 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.4 pts better | 1.3 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.7 pts better | 95.1% | 93.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine8.7 pts worse | 85.0% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.2 pts worse | 4.6% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms3.5 pts better | 5.3% | 8.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.3 pts worse | 7.1% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication6.1 pts better | 5.5% | 11.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication18.9 pts worse | 38.8% | 19.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.6 pts worse | 12.3% | 11.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.2 pts better | 9.6% | 12.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts better | 0.0% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.9 pts worse | 2.3% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2 pts worse | 22.6% | 20.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1 pts worse | 4.4% | 3.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine28 pts worse | 49.0% | 77.0% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.6 pts better | 0.0% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine37.2 pts worse | 36.4% | 73.6% | 80.1% |
·
Fire safety
19 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- F
Install an approved automatic sprinkler system.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
Gas, Vacuum, and Electrical Systems4F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have proper medical gas storage and administration areas.
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Emergency Preparedness4F
- F
Develop a communication plan.
- F
Establish emergency prep training and testing.
- F
Establish staff and initial training requirements.
- F
Develop and maintain an Emergency Preparedness Program (EP).
Services3F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Meet other general requirements that are deficient.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Egress2E
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Construction1F
- F
Use approved construction type or materials.
Miscellaneous1E
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
·
Other homes nearby
-
Columbine Commons Health And Rehab LLC
Windsor, CO
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 59 min
- Fines
- $0
-
★★★★★
- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 41 min
- Fines
- $0
-
Center At Centerplace, LLC, The
Greeley, CO · Veritas Management Group
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 5 h 20 min
- Fines
- $31,360