nursing home in Windsor, CO
Pelican Pointe Health and Rehabilitation Center
710 3rd St, Windsor, CO 80550 · (970) 686-7474
★★★★★1
Much below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★1
- Staffing★★★★★4
- Quality measures★★★★★3
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Pelican Pointe Health and Rehabilitation Center at a glance
Pelican Pointe Health and Rehabilitation Center is a 104-bed for-profit nursing home in Windsor, Colorado (Weld County).
CMS gives it 1 out of 5 stars on its overall star rating, worse than the Colorado average of 3.2.
Residents receive about 3.3 hours of nursing care per day (0.8 of them from registered nurses), worse than the state average of 3.7 hours.
Its most recent standard health inspection (January 15, 2026) found 10 health citations. The Colorado average is 8.7.
Federal regulators fined it 4 times in the past three years, totaling $71,640.
Nursing staff turnover is 53.7% per year (state average 47.1%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Corporation
- Beds
- 104
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- The Ensign Group
- Medicare-certified since
- June 1, 1990
- Resident/family council
- Both
- County
- Weld County
- CMS Certification Number
- 065278
Ratings
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 1 / 5 | 3.2 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 1 / 5 | 2.7 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 4 / 5 | 3.2 / 5 | 2.9 / 5 | Better |
| Quality measures rating ⓘ (higher is better) | 3 / 5 | 4.1 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 3 / 5 | 4.1 / 5 | 3.8 / 5 | Worse |
Staffing
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.33 hrs | 3.72 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.84 hrs | 0.82 hrs | 0.69 hrs | Better |
| Nurse aide hours per resident per day (higher is better) | 2.12 hrs | 2.21 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 2.97 hrs | 3.29 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 53.7% | 47.1% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 31.6% | 44.6% | 42.9% | Better |
| Administrators who left in the past year (lower is better) | 1 | 0 | 1 | Worse |
Inspections
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 10 | 9 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 4 | 2 | 3 | Worse |
| Weighted health inspection score ⓘ (lower is better) | 122.8 | 74 | 80.6 | Worse |
Penalties
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 4 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $71,640 | $22,802 | $30,972 | Worse |
| All federal penalties in the past 3 years (lower is better) | 4 | 1 | 1 | Worse |
Size
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 104 | 94 | 107 | |
| Average residents per day | 86 | 75 | 86 | |
| Occupancy | 82.2% | 80.7% | 80.9% |
Long-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 4.9% | 3.4% | 3.2% | Worse |
| Long-stay residents with pressure ulcers (lower is better) | 4.8% | 3.4% | 4.6% | Average |
| Long-stay residents given antipsychotic medication (lower is better) | 38.9% | 20% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 1.6% | 1.4% | 1.6% | Average |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.6% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 10.2% | 13.4% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 16.4% | 13.3% | 14.1% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 8.6% | 4.7% | 5.2% | Worse |
| Long-stay residents with depressive symptoms (lower is better) | 2.8% | 8.8% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 5.9% | 11.5% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 28.4% | 21.2% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 93.7% | 94.7% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 96.4% | 93.5% | 93.6% | Average |
Short-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 3.1% | 1.6% | 1.6% | Worse |
| Short-stay residents given a flu vaccine (higher is better) | 65.9% | 75.6% | 79.8% | Worse |
| Short-stay residents given a pneumonia vaccine (higher is better) | 57.9% | 76.4% | 82% | Worse |
Inspection citations
State inspectors cited this home for 42 health deficiencies and 19 fire safety deficiencies in the inspection records CMS currently publishes. 4 citations involved actual harm, including 1 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| July 21, 2026 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Past Non-Compliance |
| May 19, 2026 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | G Actual harm, isolated | Corrected June 5, 2026 |
| May 19, 2026 Complaint | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected June 5, 2026 |
| May 19, 2026 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected June 5, 2026 |
| January 15, 2026 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | F Potential harm, widespread | Corrected August 10, 2026 |
| January 15, 2026 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | F Potential harm, widespread | No revisit needed |
| January 15, 2026 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected March 6, 2026 |
| January 15, 2026 Fire safety | Use approved construction type or materials. Construction Deficiencies · Tag K0161 | F Potential harm, widespread | Corrected February 10, 2027 |
| January 15, 2026 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected April 20, 2026 |
| January 15, 2026 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | E Potential harm, pattern | Corrected February 25, 2026 |
| January 15, 2026 Fire safety | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0927 | E Potential harm, pattern | Corrected March 27, 2026 |
| January 15, 2026 Fire safety | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0923 | E Potential harm, pattern | Corrected March 10, 2026 |
| January 15, 2026 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | E Potential harm, pattern | Corrected March 9, 2026 |
| January 15, 2026 Fire safety | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Tag K0223 | E Potential harm, pattern | Corrected March 9, 2026 |
| January 15, 2026 Fire safety | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Tag K0374 | E Potential harm, pattern | Corrected February 10, 2027 |
| January 15, 2026 Fire safety | Meet other general requirements that are deficient. Services Deficiencies · Tag K0500 | E Potential harm, pattern | Corrected March 11, 2026 |
| January 15, 2026 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected February 7, 2026 |
| January 15, 2026 Standard | 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 · Tag F0605 | D Potential harm, isolated | Corrected February 7, 2026 |
| January 15, 2026 Standard | 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 · Tag F0657 | D Potential harm, isolated | Corrected February 7, 2026 |
| January 15, 2026 Standard | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0698 | D Potential harm, isolated | Corrected February 7, 2026 |
| January 15, 2026 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected February 7, 2026 |
| January 15, 2026 Standard | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Tag F0881 | D Potential harm, isolated | Corrected February 7, 2026 |
| July 15, 2025 Complaint | 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 · Tag F0600 | J Immediate jeopardy, isolated | Corrected August 8, 2025 |
| July 15, 2025 Complaint | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Tag F0867 | F Potential harm, widespread | Corrected August 8, 2025 |
| July 15, 2025 Complaint | Employ staff that are licensed, certified, or registered in accordance with state laws. Administration Deficiencies · Tag F0839 | F Potential harm, widespread | Corrected August 8, 2025 |
| February 4, 2025 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. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected February 19, 2025 |
| June 10, 2024 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected June 12, 2024 |
| June 10, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected June 11, 2024 |
| June 10, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | E Potential harm, pattern | Corrected June 11, 2024 |
| December 11, 2023 Fire safety | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0914 | F Potential harm, widespread | Corrected January 12, 2024 |
| December 11, 2023 Fire safety | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Tag E0004 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Fire safety | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Tag E0037 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Fire safety | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Tag E0036 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Fire safety | Develop a communication plan. Emergency Preparedness Deficiencies · Tag E0029 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | D Potential harm, isolated | Corrected January 12, 2024 |
| December 11, 2023 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | G Actual harm, isolated | Corrected December 29, 2023 |
| December 11, 2023 Standard | 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 · Tag F0838 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Tag F0867 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Tag F0883 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Keep all essential equipment working safely. Environmental Deficiencies · Tag F0908 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0943 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Tag F0944 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Tag F0949 | F Potential harm, widespread | Corrected December 29, 2023 |
| December 11, 2023 Standard | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Tag F0744 | E Potential harm, pattern | Corrected December 29, 2023 |
| December 11, 2023 Standard | 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 · Tag F0600 | D Potential harm, isolated | Corrected December 29, 2023 |
| December 11, 2023 Standard | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Tag F0806 | D Potential harm, isolated | Corrected December 29, 2023 |
| December 11, 2023 Standard | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected December 29, 2023 |
| December 11, 2023 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | D Potential harm, isolated | Corrected December 29, 2023 |
| December 11, 2023 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. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected December 29, 2023 |
| December 11, 2023 Standard | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Tag F0658 | D Potential harm, isolated | Corrected December 29, 2023 |
| December 11, 2023 Standard | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Tag F0660 | D Potential harm, isolated | Corrected December 29, 2023 |
| August 25, 2022 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | F Potential harm, widespread | Waiver has been granted |
| August 25, 2022 Standard | 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 · Tag F0600 | G Actual harm, isolated | Corrected September 28, 2022 |
| August 25, 2022 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected September 28, 2022 |
| August 25, 2022 Standard | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Tag F0925 | F Potential harm, widespread | Corrected September 28, 2022 |
| August 25, 2022 Standard | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Tag F0744 | E Potential harm, pattern | Corrected September 28, 2022 |
| August 25, 2022 Standard | 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. Administration Deficiencies · Tag F0849 | D Potential harm, isolated | Corrected September 28, 2022 |
| August 25, 2022 Standard | 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. Resident Rights Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected September 28, 2022 |
| August 25, 2022 Standard | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected September 28, 2022 |
| August 25, 2022 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected September 28, 2022 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 4 federal penalties in the past three years, including $71,640 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| July 15, 2025 | Fine | $28,780 |
| December 11, 2023 | Fine | $30,862 |
| November 20, 2023 | Fine | $3,529 |
| October 30, 2023 | Fine | $8,469 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| ownership data not available |
Other nursing homes near Pelican Pointe Health and Rehabilitation Center
Columbine Commons Health and Rehab LLC
1475 Main St, Windsor, CO 80550 · 1.6 mi
For-profit · 60 beds
- CMS high performer
★★★★★5Much above averageGrace Pointe Cont Care Sr Campus, Skilled Nursing
1919 68th Ave, Greeley, CO 80634 · 7.3 mi
For-profit · 53 beds
★★★★★5Much above averageCenter at Centerplace, LLC, the
4356 24th St Rd, Greeley, CO 80634 · 8.6 mi
For-profit · 54 beds · Part of Veritas Management Group
★★★★★2Below averageLemay Avenue Health and Rehab LLC
4824 S Lemay Ave, Fort Collins, CO 80525 · 9 mi
For-profit · 130 beds
★★★★★4Above averageLife Care Center of Greeley
4800 W 25th St, Greeley, CO 80634 · 9 mi
For-profit · 124 beds · Part of Life Care Centers of America
★★★★★5Much above averageWestlake Health and Rehabilitation Center
1637 29th Ave Pl, Greeley, CO 80634 · 9.9 mi
For-profit · 107 beds · Part of The Ensign Group
★★★★★4Above average
Frequently asked questions
What is Pelican Pointe Health and Rehabilitation Center's rating?
Pelican Pointe Health and Rehabilitation Center has 1 out of 5 stars on the CMS overall star rating. The average for Colorado nursing homes is 3.2 stars.
How many inspection citations did Pelican Pointe Health and Rehabilitation Center receive?
Its most recent standard health inspection found 10 citations, compared with a Colorado average of 8.7. Every citation is listed on this page with its severity.
Does Pelican Pointe Health and Rehabilitation Center accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Pelican Pointe Health and Rehabilitation Center?
It is for profit - corporation and part of The Ensign Group. The ownership section on this page lists the owners and managers reported to CMS.
Where is Pelican Pointe Health and Rehabilitation Center and how do I contact it?
Pelican Pointe Health and Rehabilitation Center is at 710 3rd St, Windsor, CO 80550. Phone: (970) 686-7474.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.