Pelican Pointe Health And Rehabilitation Center
Pelican Pointe Health And Rehabilitation Center is a 1-star rated nursing home in Windsor, CO with 104 beds. CMS sub-ratings: health inspections 1/5, staffing 4/5, quality measures 3/5.
The facility has 75 health violations on record. Federal fines total $85,950 across 10 enforcement actions. Most recent inspection: February 4, 2025.
This facility has abuse citations on its federal record.
Designated as a CMS Special Focus Facility — indicating a pattern of serious quality issues under heightened federal oversight.
Staff turnover rate: 80.2% — significantly above the national average.
Data synthesized from CMS.gov and Colorado public inspection records. Reviewed by Christopher F. Nesbitt, Sr., NR-EMT & BU-trained Paralegal.
Inspection History Overview
Data current as of May 6, 2026 · Source: CMS Provider Data
Detailed Inspection Reports
No detailed inspection reports available yet. Check back soon as we're processing new reports daily.
Fines and Penalties by Year
2022 5 penalties totaling $35,245
Fine
Fine
Fine
Fine
Payment Denial
2021 5 penalties totaling $50,705
Fine
Fine
Fine
Fine
Fine
Health Violations by Year
2025 1 violations
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.
2024 3 violations
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide and implement an infection prevention and control program.
2023 19 violations
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure services provided by the nursing facility meet professional standards of quality.
Plan the resident's discharge to meet the resident's goals and needs.
Provide enough food/fluids to maintain a resident's health.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Keep all essential equipment working safely.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2022 15 violations
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Ensure that residents are free from significant medication errors.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Provide and implement an infection prevention and control program.
2021 13 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to organize and participate in resident/family groups in the facility.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate pain management for a resident who requires such services.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Dispose of garbage and refuse properly.
Provide and implement an infection prevention and control program.
2020 2 violations
Provide and implement an infection prevention and control program.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2019 2 violations
Provide care by qualified persons according to each resident's written plan of care.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
2018 8 violations
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
PASARR screening for Mental disorders or Intellectual Disabilities
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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.
Provide and implement an infection prevention and control program.
2016 12 violations
Keep each resident free from physical restraints, unless needed for medical treatment.
Provide clean bed and bath linens that are in good condition.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment.
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Store, cook, and serve food in a safe and clean way.
Have a program that investigates, controls and keeps infection from spreading.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
Frequently Asked Questions About Pelican Pointe Health And Rehabilitation Center
- What violations has Pelican Pointe Health And Rehabilitation Center received?
- Pelican Pointe Health And Rehabilitation Center has 75 health and safety violation(s) documented by CMS inspections. All violation data comes from official Medicare inspection reports and is updated regularly from government sources.
- What is the quality rating of Pelican Pointe Health And Rehabilitation Center?
- Pelican Pointe Health And Rehabilitation Center has a 1-star rating out of 5 from CMS. This rating indicates the facility may have quality concerns that should be investigated further. The rating is based on health inspections, staffing levels, and quality measures.
- When was Pelican Pointe Health And Rehabilitation Center last inspected?
- Inspection reports are documented by state survey agencies and the Centers for Medicare & Medicaid Services (CMS). Reports typically lag 2-3 months behind the actual inspection date. Visit the facility's full profile page for detailed violation information and inspection history.
- Is Pelican Pointe Health And Rehabilitation Center safe?
- Safety at Pelican Pointe Health And Rehabilitation Center should be evaluated based on multiple factors: the facility's CMS rating, recent violation history, and personal visits. We recommend reviewing the complete inspection history, speaking with current residents and families, consulting healthcare professionals, and visiting in person before making placement decisions.
- How do I contact Pelican Pointe Health And Rehabilitation Center?
- Phone: (970) 686-7474. Address: 710 3rd St, Windsor, CO. For visiting hours and admission information, call the facility directly.
- What services does Pelican Pointe Health And Rehabilitation Center offer?
- Pelican Pointe Health And Rehabilitation Center is a skilled nursing facility with 104 beds. The facility accepts Medicare and Medicaid. For specific services like rehabilitation, memory care, or short-term recovery, contact the facility directly.
- What are better facilities near Windsor, CO?
- Compare Pelican Pointe Health And Rehabilitation Center with other nursing homes in Windsor, CO on our facilities page. Filter by star rating, bed count, and recent inspection results to find the best match for your needs.
Compare Nursing Homes in Windsor, CO
| Facility | Rating | Violations | Beds |
|---|---|---|---|
| Pelican Pointe Health And Rehabilitation Center (this facility) | ★☆☆☆☆ | 75 | 104 |
| Columbine Commons Health And Rehab Llc | ★★★★★ | 0 | 30 |
| Columbine Commons Health And Rehab Llc | ★★★★★ | 17 | 60 |
| Windsor Health Care Center | ★★★☆☆ | 0 | 104 |
Editorial Standards & Data Oversight
Data Source: This report is based on official public inspection records from the Centers for Medicare & Medicaid Services (CMS) Provider Data Catalog.
Editorial Process: Content generated using AI to synthesize complex regulatory data, then reviewed and verified for accuracy by our editorial team.
Professional Review: All content undergoes standards and compliance oversight by Christopher F. Nesbitt, Sr., Nationally Registered EMT & BU-trained Paralegal, using professional regulatory data auditing protocols.
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