Pelican Pointe Health and Rehabilitation Center
710 3rd St, Windsor, CO 80550
Pelican Pointe Health and Rehabilitation Center is a nursing home in Windsor, Colorado. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionJanuary 15, 2026 (9 months ago)
- Health citations since August 25, 202242 (Colorado average 25)
- Fines in the past three years5, $78,577 in total
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Email alerts for this home open soon.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
Fine
CMS changed the fine from July 15, 2025 from $28,780 to $18,707.
CMS update of October 8, 2026
CMS abuse icon
CMS removed its abuse icon from this home.
Name
CMS lists a new legal business name for this home.
Health inspection on July 21, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS has cited this home for F0609 2 times since 2023.
CMS update of June 24, 2026
Ownership
CMS ownership records list new owners for this home.
CMS update of May 27, 2026
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Health inspection on May 19, 2026
3 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
38 of 210 Colorado homes (18%) got a citation at the actual harm level in 2026.
CMS fine of $17,010 on May 19, 2026.
Show the 3 citations
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 5, 2026.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0760 2 times since 2022.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0880 4 times since 2023.
CMS update of April 29, 2026
Staffing
Total nurse staffing reported to CMS went from 3.8 to 3.4 hours per resident per day.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Health inspection on January 15, 2026
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on February 7, 2026.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on February 7, 2026.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on February 7, 2026.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on February 7, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 7, 2026.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on February 7, 2026.
Fire safety inspection on January 15, 2026
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on February 10, 2027.
Citation K0351. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on August 10, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 20, 2026.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS has cited this home for K0521 2 times since 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 6, 2026.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on March 9, 2026.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on March 9, 2026.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on February 10, 2027.
Citation K0500. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet other general requirements that are deficient.
CMS lists it as corrected on March 11, 2026.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on February 25, 2026.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on March 10, 2026.
Citation K0927. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on March 27, 2026.
CMS update of December 15, 2025
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Name
CMS lists a new legal business name for this home.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on July 15, 2025
3 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
25 of 210 Colorado homes (12%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $18,707 on July 15, 2025.
Show the 3 citations
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 8, 2025.
CMS has cited this home for F0600 3 times since 2022.
Citation F0839. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Employ staff that are licensed, certified, or registered in accordance with state laws.
CMS lists it as corrected on August 8, 2025.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on August 8, 2025.
CMS has cited this home for F0867 2 times since 2023.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 3.3 to 1.1 hours per resident per day.
Health inspection on February 4, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 19, 2025.
CMS has cited this home for F0585 2 times since 2023.
CMS update of December 20, 2024
Fine
CMS changed the fine from December 11, 2023 from $30,388 to $30,862.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Fine
CMS changed the fine from August 25, 2022 from $23,465 to $23,959.
CMS update of June 26, 2024
Fine
CMS changed the fine from October 30, 2023 from $8,391 to $8,468.
Fine
CMS changed the fine from November 20, 2023 from $3,496 to $3,529.
Health inspection on June 10, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 12, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 11, 2024.
CMS has cited this home for F0689 2 times since 2022.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 11, 2024.
CMS update of March 28, 2024
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.5 to 2.5 hours per resident per day.
Health inspection on December 11, 2023
17 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
55 of 210 Colorado homes (26%) got a citation at the actual harm level in 2023.
CMS fine of $30,862 on December 11, 2023.
Show the 17 citations
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on December 29, 2023.
Citation F0838. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on December 29, 2023.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on December 29, 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 29, 2023.
Citation F0883. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on December 29, 2023.
Citation F0908. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on December 29, 2023.
Citation F0943. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on December 29, 2023.
Citation F0944. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on December 29, 2023.
Citation F0949. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on December 29, 2023.
Citation F0744. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on December 29, 2023.
CMS has cited this home for F0744 2 times since 2022.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 29, 2023.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 29, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 29, 2023.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on December 29, 2023.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on December 29, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 29, 2023.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on December 29, 2023.
Fire safety inspection on December 11, 2023
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on December 29, 2023.
Citation E0029. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop a communication plan.
CMS lists it as corrected on December 29, 2023.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on December 29, 2023.
Citation E0037. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on December 29, 2023.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on January 12, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on January 12, 2024.
November 20, 2023
FineCMS fine of $3,529 on November 20, 2023.
October 30, 2023
FineCMS fine of $8,469 on October 30, 2023.
Health inspection on August 25, 2022
8 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
45 of 210 Colorado homes (21%) got a citation at the actual harm level in 2022.
Show the 8 citations
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on September 28, 2022.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 28, 2022.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on September 28, 2022.
Citation F0744. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on September 28, 2022.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 28, 2022.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 28, 2022.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on September 28, 2022.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 28, 2022.
Fire safety inspection on August 25, 2022
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (970) 686-7474
- Last standard health inspection
- January 15, 2026 (9 months ago)
- Certified beds
- 104
- Residents per day, on average
- 88.9
- Ownership type
- For profit - Corporation
- Legal business name
- Legal Business Name Not Available
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
More health citations than the Colorado average (42 vs 25).
Questions
When was Pelican Pointe Health and Rehabilitation Center last inspected?
CMS lists January 15, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Pelican Pointe Health and Rehabilitation Center have?
CMS lists 42 health citations since August 25, 2022. CMS also calls these deficiencies.
Has Pelican Pointe Health and Rehabilitation Center been fined?
CMS lists 5 fines in the past three years, $78,577 in total.
What is the CMS star rating of Pelican Pointe Health and Rehabilitation Center?
Its CMS overall star rating is 2 of 5.
Is Pelican Pointe Health and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.