Nursing home report card · Windsor, CO
Pelican Pointe Health and Rehabilitation Center
710 3rd ST, Windsor, CO 80550
Call this home: (970) 686-7474
View this home on Medicare.gov ↗
Quick summary
Below-average Medicare rating
Overall rating is 1 of 5 stars. Its health-inspection rating is 1 of 5. Read the dated inspection findings and separate staffing and care ratings below.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Jan 15, 2026
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Among the lowest Medicare ratings
Based on problems found during health inspections.
Among the lowest Medicare ratings
Based on staffing levels and related measures.
Above average
Based on reported health and care results.
About average for U.S. nursing homes
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 065278
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Immediate danger to residents · isolated case
Jul 15, 2025 · Inspection rule 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Caused actual harm · isolated case
May 19, 2026 · Inspection rule 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Caused actual harm · isolated case
Dec 11, 2023 · Inspection rule 0692
Provide enough food/fluids to maintain a resident's health.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 50 minutes per resident per day
about 3 hr 20 min per resident per day
about 33 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 1 stars
- Health inspection rating: 1 stars
- Staffing rating: 4 stars
- Registered nurse time per resident: 0.84 hours/day
- Total nurse time per resident: 3.33 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; Colorado averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Overall star rating is 2 or lower
- Health inspection rating is 2 stars or lower
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
- CMS has fined this home in the recent reporting period
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Immediate danger to residents1 citation
- Caused actual harm3 citations
- Could have caused harm39 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 43
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Corporation.
- We do not have individual owner names for this home.
Other homes in this group: All The Ensign Group nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
May 19, 20263 findings
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code D
Ensure that residents are free from significant medication errors.
January 15, 20266 findings
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0881 · code D
Implement a program that monitors antibiotic use.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0698 · code D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0605 · code D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
July 15, 20253 findings
- Freedom from Abuse, Neglect, and Exploitation problemsImmediate danger to residents · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0867 · code F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0839 · code F
Employ staff that are licensed, certified, or registered in accordance with state laws.
February 4, 20251 finding
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0585 · code 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.
June 10, 20243 findings
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code E
Provide and implement an infection prevention and control program.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0677 · code E
Provide care and assistance to perform activities of daily living for any resident who is unable.
December 11, 202317 findings
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0806 · code D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code D
Ensure services provided by the nursing facility meet professional standards of quality.
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0692 · code G
Provide enough food/fluids to maintain a resident's health.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0838 · code 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.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0867 · code F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- Infection Control problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code F
Provide and implement an infection prevention and control program.
- Infection Control problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0883 · code F
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- Environmental problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0908 · code F
Keep all essential equipment working safely.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0943 · code F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0944 · code F
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0949 · code F
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0744 · code E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0585 · code 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.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
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 problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0660 · code D
Plan the resident's discharge to meet the resident's goals and needs.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code 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.
August 7, 20232 findings
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code E
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.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
August 25, 20228 findings
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code D
Ensure that residents are free from significant medication errors.
- Freedom from Abuse, Neglect, and Exploitation problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Environmental problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0925 · code F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0744 · code E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code 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.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Administration problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0849 · code 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.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Fine · Jul 15, 2025$28,780
- Fine · Dec 11, 2023$30,862
- Fine · Nov 20, 2023$3,529
- Fine · Oct 30, 2023$8,469
Other homes in this chain
The Ensign Group · other locations in Colorado
- Medallion Post Acute Rehabilitation · Colorado Springs1 of 5 · 26 problems
- Rock Canyon Respiratory and Rehabilitation Center · Pueblo1 of 5 · 41 problems
- Oakwood Care and Rehabilitation · Lakewood1 of 5 · 72 problems
- Durango Health and Rehabilitation · Durango1 of 5 · 48 problems
- Irondale Post Acute · Commerce City2 of 5 · 27 problems
- Parker Post Acute · Parker2 of 5 · 28 problems
- Malley Transitional Care Center · Northglenn2 of 5 · 29 problems
- Villas at Sunny Acres, The · Thornton2 of 5 · 28 problems
Related topics
Questions about Pelican Pointe Health and Rehabilitation Center
What is Pelican Pointe Health and Rehabilitation Center's Medicare star rating?
Has Pelican Pointe Health and Rehabilitation Center been fined?
Does Pelican Pointe Health and Rehabilitation Center have a Medicare abuse warning?
How does Pelican Pointe Health and Rehabilitation Center compare with other nursing homes in Colorado?
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