Starfile / Colorado

PELICAN POINTE HEALTH AND REHABILITATION CENTER

710 3RD ST, WINDSOR, CO 80550 · CCN 065278

SFF Candidate Abuse icon

Inspection history vs Colorado & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$42,860

Number of fines

3

Number of penalties

3

Payment denials

0

Chain

Chain

THE ENSIGN GROUP

Facilities in chain

329

Chain avg overall

3.20 / 5

Inspection citations (47)1 immediate jeopardy3 actual harm

1. JF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-07-15 · Health · corrected 2025-08-08

   Immediate jeopardy

2. FF0839Employ staff that are licensed, certified, or registered in accordance with state laws.2025-07-15 · Health · corrected 2025-08-08

   Potential for more than minimal harm

3. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2025-07-15 · Health · corrected 2025-08-08

   Potential for more than minimal harm

4. DF0585Honor 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.2025-02-04 · Health · corrected 2025-02-19

   Potential for more than minimal harm

5. EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-06-10 · Health · corrected 2024-06-12

   Potential for more than minimal harm

6. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-06-10 · Health · corrected 2024-06-11

   Potential for more than minimal harm

7. EF0880Provide and implement an infection prevention and control program.2024-06-10 · Health · corrected 2024-06-11

   Potential for more than minimal harm

8. DF0585Honor 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.2023-12-11 · Health · corrected 2023-12-29

   Potential for more than minimal harm

9. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-12-11 · Health · corrected 2023-12-29

   Potential for more than minimal harm

10. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

11. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

12. DF0660Plan the resident's discharge to meet the resident's goals and needs.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

13. GF0692Provide enough food/fluids to maintain a resident's health.2023-12-11 · Health · corrected 2023-12-29

    Actual harm

14. EF0744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

15. DF0761Ensure 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.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

16. DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

17. FF0838Conduct 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.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

18. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

19. FF0880Provide and implement an infection prevention and control program.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

20. FF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

21. FF0908Keep all essential equipment working safely.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

22. FF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

23. FF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

24. FF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2023-12-11 · Health · corrected 2023-12-29

    Potential for more than minimal harm

25. EF0584Honor 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.2023-08-07 · Health · corrected 2023-08-08

    Potential for more than minimal harm

26. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-08-07 · Health · corrected 2023-08-08

    Potential for more than minimal harm

27. DF0584Honor 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.2022-08-25 · Health · corrected 2022-09-28

    Potential for more than minimal harm

28. GF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2022-08-25 · Health · corrected 2022-09-28

    Actual harm

29. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-08-25 · Health · corrected 2022-09-28

    Potential for more than minimal harm

30. EF0744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.2022-08-25 · Health · corrected 2022-09-28

    Potential for more than minimal harm

31. DF0760Ensure that residents are free from significant medication errors.2022-08-25 · Health · corrected 2022-09-28

    Potential for more than minimal harm

32. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-08-25 · Health · corrected 2022-09-28

    Potential for more than minimal harm

33. DF0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.2022-08-25 · Health · corrected 2022-09-28

    Potential for more than minimal harm

34. FF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2022-08-25 · Health · corrected 2022-09-28

    Potential for more than minimal harm

35. GF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2021-06-15 · Health · corrected 2021-07-22

    Actual harm

36. EF0565Honor the resident's right to organize and participate in resident/family groups in the facility.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

37. DF0585Honor 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.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

38. EF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

39. DF0603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

40. DF0695Provide safe and appropriate respiratory care for a resident when needed.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

41. DF0697Provide safe, appropriate pain management for a resident who requires such services.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

42. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

43. EF0744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

44. EF0761Ensure 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.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

45. EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

46. FF0814Dispose of garbage and refuse properly.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

47. EF0880Provide and implement an infection prevention and control program.2021-06-15 · Health · corrected 2021-07-22

    Potential for more than minimal harm

Ownership

Other facilities in WINDSOR

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.