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Pelican Pointe Health and Rehabilitation Center

Nursing HomeWindsor, COCMS 065278
53 citations on record

Operated by The Ensign Group

From CMS

Facility profile

CMS overall rating
1 / 5

*CMS Five-Star

Certified beds
104

*CMS

Avg. residents per day
84.8

*CMS

Inspection record

On record from CMS

Health citations
53

*CMS

Fire safety findings
22

*CMS

Inspections on file
12

*CMS

Last inspection
2026-01-15

*CMS

Citations

53 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0698Generalpotential for harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0686Generalpotential for harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0605Generalpotential for harm

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0867Generalpotential for harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0839Generalpotential for harm

    Employ staff that are licensed, certified, or registered in accordance with state laws.

  • 0600Seriousimmediate jeopardy

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0585Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0744Generalpotential for harm

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  • 0585Generalpotential for harm

    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.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0660Generalpotential for harm

    Plan the resident's discharge to meet the resident's goals and needs.

  • 0692Seriousactual harm

    Provide enough food/fluids to maintain a resident's health.

  • 0761Generalpotential for harm

    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.

  • 0806Generalpotential for harm

    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  • 0838Generalpotential for harm

    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.

  • 0867Generalpotential for harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0908Generalpotential for harm

    Keep all essential equipment working safely.

  • 0943Generalpotential for harm

    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  • 0944Generalpotential for harm

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  • 0949Generalpotential for harm

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0584Generalpotential for harm

    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.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0584Generalpotential for harm

    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.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0744Generalpotential for harm

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0849Generalpotential for harm

    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.

  • 0925Generalpotential for harm

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  • 0600Seriousactual harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0585Generalpotential for harm

    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.

  • 0565Generalpotential for harm

    Honor the resident's right to organize and participate in resident/family groups in the facility.

  • 0550Seriousactual harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0814Generalpotential for harm

    Dispose of garbage and refuse properly.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0804Generalpotential for harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0761Generalpotential for harm

    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.

  • 0744Generalpotential for harm

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  • 0725Generalpotential for harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0697Generalpotential for harm

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0603Generalpotential for harm

    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

Showing the 10 most recent inspections. 2 earlier inspections are also on record.

Ownership

The Ensign Group

338nursing homes nationwide, in CMS records

See the full ownership footprint

FAQ

Questions and answers

What is Pelican Pointe Health and Rehabilitation Center?
Pelican Pointe Health and Rehabilitation Center is a Medicare- and Medicaid-certified nursing home in Windsor, CO, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 065278.
What is the CMS rating for Pelican Pointe Health and Rehabilitation Center?
Pelican Pointe Health and Rehabilitation Center has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Pelican Pointe Health and Rehabilitation Center have?
Pelican Pointe Health and Rehabilitation Center is certified for 104 beds. It serves an average of 84.8 residents per day.
How many citations does Pelican Pointe Health and Rehabilitation Center have?
Pelican Pointe Health and Rehabilitation Center has 53 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Pelican Pointe Health and Rehabilitation Center last inspected?
Pelican Pointe Health and Rehabilitation Center was last inspected on January 15, 2026. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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