Pelican Pointe Health and Rehabilitation CenterCMS ratings, inspections and fines
- Address
- 710 3rd St, Windsor, CO 80550
- CCN
- 065278
- Ownership type
- For-profit, corporation
- Certified beds
- 104
- Chain
- The Ensign Group
- Residents per day
- 86
- CMS flags
- None in the CMS record
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Pelican Pointe Health and Rehabilitation Center an overall rating of 1 of 5 stars. The last standard survey was on 15 Jan 2026. The latest survey cycle has 9 health citations. The median for nursing homes in Colorado is 8. CMS lists 4 fines with a total of $71,640 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Weld County median | Colorado median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 1 | 4.0 | 3.0 | 3.0 |
| Health inspection rating | 1 | 4.0 | 2.0 | 2.8 |
| Staffing rating | 4 | 4.0 | 3.0 | 2.9 |
| Quality measure rating | 3 | 4.0 | 5.0 | 3.6 |
A median is the middle value of the homes in the group: 8 homes in the county, 210 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Colorado median |
|---|---|---|---|
| Cycle 1 (latest) | 15 Jan 2026 | 9 | 8 |
| Cycle 2 | 11 Dec 2023 | 21 | 8 |
| Cycle 3 | No date | 13 | 6 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | K0 | L0 | |
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 9 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 19 May 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | Complaint investigation | 5 Jun 2026 |
| 19 May 2026 | F0760 | Ensure that residents are free from significant medication errors. | D | Complaint investigation | 5 Jun 2026 |
| 19 May 2026 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 5 Jun 2026 |
| 15 Jan 2026 | F0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D | Standard survey | 7 Feb 2026 |
| 15 Jan 2026 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 7 Feb 2026 |
| 15 Jan 2026 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 7 Feb 2026 |
| 15 Jan 2026 | F0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard survey | 7 Feb 2026 |
| 15 Jan 2026 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 7 Feb 2026 |
| 15 Jan 2026 | F0881 | Implement a program that monitors antibiotic use. | D | Standard survey | 7 Feb 2026 |
Survey cycle 2: 21 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 15 Jul 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint investigation | 8 Aug 2025 |
| 15 Jul 2025 | F0839 | Employ staff that are licensed, certified, or registered in accordance with state laws. | F | Complaint investigation | 8 Aug 2025 |
| 15 Jul 2025 | F0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Complaint investigation | 8 Aug 2025 |
| 4 Feb 2025 | F0585 | 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. | D | Complaint investigation | 19 Feb 2025 |
| 11 Dec 2023 | F0585 | 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. | D | Complaint investigation | 29 Dec 2023 |
| 11 Dec 2023 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0660 | Plan the resident's discharge to meet the resident's goals and needs. | D | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0692 | Provide enough food/fluids to maintain a resident's health. | G | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0761 | 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. | D | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0838 | 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. | F | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0880 | Provide and implement an infection prevention and control program. | F | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | F | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0908 | Keep all essential equipment working safely. | F | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | F | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | F | Standard survey | 29 Dec 2023 |
| 11 Dec 2023 | F0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | F | Standard survey | 29 Dec 2023 |
Survey cycle 3: 13 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 10 Jun 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Complaint investigation | 12 Jun 2024 |
| 10 Jun 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Complaint investigation | 11 Jun 2024 |
| 10 Jun 2024 | F0880 | Provide and implement an infection prevention and control program. | E | Complaint investigation | 11 Jun 2024 |
| 7 Aug 2023 | F0584 | 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. | E | Complaint investigation | 8 Aug 2023 |
| 7 Aug 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 8 Aug 2023 |
| 25 Aug 2022 | F0584 | 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. | D | Standard survey | 28 Sep 2022 |
| 25 Aug 2022 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Standard survey | 28 Sep 2022 |
| 25 Aug 2022 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 28 Sep 2022 |
| 25 Aug 2022 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E | Standard survey | 28 Sep 2022 |
| 25 Aug 2022 | F0760 | Ensure that residents are free from significant medication errors. | D | Standard survey | 28 Sep 2022 |
| 25 Aug 2022 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 28 Sep 2022 |
| 25 Aug 2022 | F0849 | 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. | D | Standard survey | 28 Sep 2022 |
| 25 Aug 2022 | F0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F | Standard survey | 28 Sep 2022 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 15 Jul 2025 | Fine | $28,780 | |
| 11 Dec 2023 | Fine | $30,862 | |
| 20 Nov 2023 | Fine | $3,529 | |
| 30 Oct 2023 | Fine | $8,469 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Colorado median | Colorado average (CMS) |
|---|---|---|---|
| All nurse staff | 3.33 | 3.50 | 3.72 |
| Registered nurses (RN) | 0.84 | 0.70 | 0.82 |
| Licensed practical nurses (LPN) | 0.36 | 0.68 | |
| Nurse aides | 2.12 | 2.22 | |
| All nurse staff, weekends | 2.97 | 3.10 | 3.30 |
- Nurse staff turnover in a year
- 53.7%
- Nurse staff turnover, Colorado median
- 46.7%
- RN turnover in a year
- 31.6%
- Administrators who left in a year
- 1
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Colorado median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.2% | 11.1% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.0% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.6% | 0.9% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.9% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 3.1% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.4% | 11.9% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.8% | 3.0% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 38.9% | 18.8% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- For-profit, corporation
- Legal business name
- Belmont Ridge Healthcare Inc
- Chain
- The Ensign Group (342 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Ensign Services Inc | Adp of the snf | 1 Sep 2024 | |
| SMV Property Holdings LLC | Adp of the snf | 1 Sep 2024 |
The site shows organisations only. It does not show the names of persons.
Other homes in Weld County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Columbine Commons Health and Rehab LLC | Windsor | 5 of 5 | 2 | $0 | 17 Apr 2025 | |
| Grace Pointe Cont Care Sr Campus, Skilled Nursing | Greeley | 5 of 5 | 3 | $0 | 26 Feb 2026 | |
| Center at Centerplace, LLC, The | Greeley | 2 of 5 | 10 | $31,360 | 22 Apr 2026 | |
| Life Care Center of Greeley | Greeley | 5 of 5 | 4 | $12,285 | 16 Jul 2024 | |
| Westlake Health and Rehabilitation Center | Greeley | 4 of 5 | 6 | $14,069 | 11 Apr 2024 | |
| Broadview Health and Rehabilitation Center | Greeley | 4 of 5 | 3 | $0 | 15 Feb 2024 | |
| Fairacres Manor, Inc. | Greeley | 4 of 5 | 3 | $0 | 6 Jun 2024 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Pelican Pointe Health and Rehabilitation Center (CCN 065278). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/pelican-pointe-health-and-rehabilitation-center-windsor-co-065278/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Pelican Pointe Health and Rehabilitation Center last inspected?
- The latest inspection with a citation in the CMS record was on 19 May 2026. It was a complaint investigation. It gave 3 citations. The standard survey before the last one was on 11 Dec 2023.
- Who operates Pelican Pointe Health and Rehabilitation Center?
- The CMS record gives the ownership type as for-profit, corporation. CMS lists the home in the chain The Ensign Group. The CMS ownership file names no organisation for operational or managerial control. This site does not show the names of persons.
- Is Pelican Pointe Health and Rehabilitation Center a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists no home in Colorado as a Special Focus Facility and 5 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.