Facility WatchInspection records for every certified US nursing home
Pelican Pointe Health and Rehabilitation Center
710 3rd ST Windsor, CO 80550 (970) 686-7474
Abuse icon
CCN
065278
Certified beds
104
Ownership
For profit - Corporation
Chain
THE Ensign Group
Nurse staffing
3.93
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.96 hours per resident per day
Nursing staff turnover: 59% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected January 15, 2026
6 citations · Health
D
F0605No actual harm with potential for more than minimal harm · Isolated
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Deficient, Provider has date of correction · corrected February 7, 2026
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected February 7, 2026
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected February 7, 2026
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected February 7, 2026
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 7, 2026
D
F0881No actual harm with potential for more than minimal harm · Isolated
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected February 7, 2026
Inspected July 15, 2025
3 citations · from a complaint investigation · Health
F
F0839No actual harm with potential for more than minimal harm · Widespread
Employ staff that are licensed, certified, or registered in accordance with state laws.
Deficient, Provider has date of correction · corrected August 8, 2025
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected August 8, 2025
J
F0600Immediate jeopardy to resident health or safety · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 8, 2025
Inspected February 4, 2025
1 citation · from a complaint investigation · Health
D
F0585No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected February 19, 2025
Inspected June 10, 2024
3 citations · from a complaint investigation · Health
E
F0677No actual harm with potential for more than minimal harm · Pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected June 12, 2024
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected June 11, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected June 11, 2024
Inspected December 11, 2023
17 citations · from a complaint investigation · Health
D
F0585No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected December 29, 2023
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected December 29, 2023
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected December 29, 2023
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected December 29, 2023
D
F0660No actual harm with potential for more than minimal harm · Isolated
Plan the resident's discharge to meet the resident's goals and needs.
Deficient, Provider has date of correction · corrected December 29, 2023
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected December 29, 2023
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected December 29, 2023
E
F0744No actual harm with potential for more than minimal harm · Pattern
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0838No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0883No actual harm with potential for more than minimal harm · Widespread
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0908No actual harm with potential for more than minimal harm · Widespread
Keep all essential equipment working safely.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0943No actual harm with potential for more than minimal harm · Widespread
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0944No actual harm with potential for more than minimal harm · Widespread
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Deficient, Provider has date of correction · corrected December 29, 2023
F
F0949No actual harm with potential for more than minimal harm · Widespread
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Deficient, Provider has date of correction · corrected December 29, 2023
G
F0692Actual harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected December 29, 2023
Inspected August 7, 2023
2 citations · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 8, 2023
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected August 8, 2023
Inspected August 25, 2022
8 citations · Health
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected September 28, 2022
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 28, 2022
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected September 28, 2022
D
F0849No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected September 28, 2022
E
F0744No actual harm with potential for more than minimal harm · Pattern
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected September 28, 2022
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected September 28, 2022
F
F0925No actual harm with potential for more than minimal harm · Widespread
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected September 28, 2022
G
F0600Actual harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected September 28, 2022