PELICAN POINTE HEALTH AND REHABILITATION CENTER
Open-data reference.
PELICAN POINTE HEALTH AND REHABILITATION CENTER is a for profit - corporation facility in WINDSOR, CO with 104 certified beds and a 1-star overall CMS rating. The facility has 47 deficiency records on file. Total penalties: $43K.
710 3RD ST, WINDSOR, CO 80550
Phone: 9706867474
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 065278
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 104
- Residents
- 83
- In Hospital
- No
- County
- Weld
- Last Inspection
- Dec 11, 2023
- Special Focus
- SFF Candidate
Staffing Data
- RN Hours
- 0.83 (nat'l avg: 0.68)
- LPN Hours
- 0.48
- CNA Hours
- 2.53
- Total Nursing Hours
- 3.84 (nat'l avg: 3.89)
- PT Hours
- 0.05
- Nursing Turnover
- 57.9%
- RN Turnover
- 43.8%
What the CMS Record Reveals About PELICAN POINTE HEALTH AND REHABILITATION CENTER
PELICAN POINTE HEALTH AND REHABILITATION CENTER operates 104 certified beds in WINDSOR, CO with approximately 83 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (4★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 47 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 3 penalties totaling $43K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.84 total nursing hours per resident day (national average 3.89), with RN coverage at 0.83 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, PELICAN POINTE HEALTH AND REHABILITATION CENTER falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 57.9%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (47 most recent)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Aug 8, 2025
Employ staff that are licensed, certified, or registered in accordance with state laws.
Category: Administration Deficiencies
Corrected: Aug 8, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 8, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Feb 19, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 11, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 11, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 12, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Dec 29, 2023
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Dec 29, 2023
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Dec 29, 2023
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 29, 2023
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Dec 29, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Dec 29, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 29, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Dec 29, 2023
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.
Category: Administration Deficiencies
Corrected: Dec 29, 2023
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 29, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Dec 29, 2023
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 29, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 29, 2023
Plan the resident's discharge to meet the resident's goals and needs.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 29, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 29, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 29, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 29, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 8, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Aug 8, 2023
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Sep 28, 2022
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.
Category: Administration Deficiencies
Corrected: Sep 28, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 28, 2022
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Sep 28, 2022
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 28, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 28, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 28, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Sep 28, 2022
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 22, 2021
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 22, 2021
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 22, 2021
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.
Category: Pharmacy Service Deficiencies
Corrected: Jul 22, 2021
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 22, 2021
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 22, 2021
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 22, 2021
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 22, 2021
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 22, 2021
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 22, 2021
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.
Category: Resident Rights Deficiencies
Corrected: Jul 22, 2021
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Jul 22, 2021
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jul 22, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 34.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 8.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.4% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.6% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.2% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.3% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 94.5% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 65.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 5.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 34.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 7.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 93.7% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 65.9% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.2% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 32.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 40.5% | Yes |
Penalty History 3 penalties totaling $43K
| Date | Type | Amount |
|---|---|---|
| Dec 11, 2023 | Fine | $31K |
| Nov 20, 2023 | Fine | $4K |
| Oct 30, 2023 | Fine | $8K |
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Understanding Nursing Home Data
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County Health Data
Health outcomes, access, and quality metrics for Weld on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for PELICAN POINTE HEALTH AND REHABILITATION CENTER?
What are the staffing levels at PELICAN POINTE HEALTH AND REHABILITATION CENTER?
How many beds does PELICAN POINTE HEALTH AND REHABILITATION CENTER have?
Does PELICAN POINTE HEALTH AND REHABILITATION CENTER have any deficiencies on record?
Has PELICAN POINTE HEALTH AND REHABILITATION CENTER received any fines or penalties?
Who owns PELICAN POINTE HEALTH AND REHABILITATION CENTER?
When was PELICAN POINTE HEALTH AND REHABILITATION CENTER last inspected?
What quality measures are tracked for PELICAN POINTE HEALTH AND REHABILITATION CENTER?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.