Pelican Pointe Health and Rehabilitation Center
710 3rd St · Windsor, CO · 80550 · 9706867474
104 certified beds For profit - Corporation Chain: The Ensign Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.41 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.83 | 0.55–0.75 |
| Weekend hours / resident-day | 3.02 | ≈ weekday level |
| Nursing turnover / year | 59% | median 45% |
| Fines (3-yr window) | 3 · $42,860 |
Inspection citations (40 in the current record)
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Potential for harm · D January 15, 2026
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected February 7, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 15, 2026
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected February 7, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 15, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 7, 2026 · Quality of Life and Care
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Potential for harm · D January 15, 2026
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected February 7, 2026 · Quality of Life and Care
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Potential for harm · D January 15, 2026
Provide and implement an infection prevention and control program.
Corrected February 7, 2026 · Infection Control
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Potential for harm · D January 15, 2026
Implement a program that monitors antibiotic use.
Corrected February 7, 2026 · Infection Control
-
Immediate jeopardy · J July 15, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 8, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F July 15, 2025 · found via complaint
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected August 8, 2025 · Administration
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Potential for harm · F July 15, 2025 · found via complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected August 8, 2025 · Administration
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Potential for harm · D February 4, 2025 · found via complaint
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.
Corrected February 19, 2025 · Resident Rights
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Potential for harm · E June 10, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected June 12, 2024 · Quality of Life and Care
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Potential for harm · E June 10, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 11, 2024 · Quality of Life and Care
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Potential for harm · E June 10, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected June 11, 2024 · Infection Control
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Actual harm · G December 11, 2023
Provide enough food/fluids to maintain a resident's health.
Corrected December 29, 2023 · Quality of Life and Care
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Potential for harm · D December 11, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 11, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 11, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 29, 2023 · Resident Assessment and Care Planning
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Potential for harm · D December 11, 2023
Plan the resident's discharge to meet the resident's goals and needs.
Corrected December 29, 2023 · Resident Assessment and Care Planning
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Potential for harm · E December 11, 2023
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected December 29, 2023 · Quality of Life and Care
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Potential for harm · D December 11, 2023
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.
Corrected December 29, 2023 · Pharmacy Service
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Potential for harm · D December 11, 2023
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected December 29, 2023 · Nutrition and Dietary
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Potential for harm · F December 11, 2023
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.
Corrected December 29, 2023 · Administration
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Potential for harm · F December 11, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected December 29, 2023 · Administration
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Potential for harm · F December 11, 2023
Provide and implement an infection prevention and control program.
Corrected December 29, 2023 · Infection Control
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Potential for harm · F December 11, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected December 29, 2023 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 11, 2023 | Fine | $30,862 |
| November 20, 2023 | Fine | $3,529 |
| October 30, 2023 | Fine | $8,469 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 065278 · certified since June 1, 1990. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.