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Data from CMS, Census Bureau & CareScout. Not affiliated with the U.S. government.

© 2026 NursingHomes.us. All data from CMS.gov.
HomeColoradoPelican Pointe Health and Rehabilitation Center

Pelican Pointe Health and Rehabilitation Center

710 3rd St, Windsor, CO 805509706867474
1/5Much Below Average
Accepts Medicare Accepts Medicaid Sprinkler System
Health
1/5
Staffing
4/5
Quality
3/5
Beds
104
certified
This facility has been flagged for abuse.
Special Focus Facility: SFF Candidate
Last health inspection was more than 2 years ago.
3 fine(s) totaling $42,860

Key Findings

• CMS rates this facility 1/5 stars (below average)

• Has 104 certified beds with an average of 82.8 residents per day (80% occupancy)

• Last health inspection found 21 deficiencies (inspected Dec 11, 2023)

• Has been fined a total of $42,860 across 3 fine(s)

• Total nursing staff: 3.84 hours per resident per day

• Staff turnover rate: 57.9% (high)

• Part of the The Ensign Group chain (324 facilities)

Pelican Pointe Health and Rehabilitation Center is a 1-star Medicare and Medicaid certified nursing home in Windsor, Colorado with 104 certified beds. It has been operating since 1990. The facility scored below average compared to Colorado facilities.

Beds
104
Avg Residents/Day
82.8
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
In Hospital
No
First Approved
Jun 1, 1990
Sprinklers
Yes
Council
Both
County
Weld
Last Inspection
Dec 11, 2023
Deficiencies (Cycle 1)
21
Weighted Score
252.3
Infection Citations
0

Deficiency Citations (47)

F0600Immediate Jeopardy

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey: Jul 15, 2025Corrected: NoCycle: 1
F0839Potential for Harm

Employ staff that are licensed, certified, or registered in accordance with state laws.

Survey: Jul 15, 2025Corrected: NoCycle: 1
F0867Potential for Harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey: Jul 15, 2025Corrected: NoCycle: 1
F0585Potential for Harm

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.

Survey: Feb 4, 2025Corrected: NoCycle: 1
F0600Potential for Harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0609Potential for Harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0658Potential for Harm

Ensure services provided by the nursing facility meet professional standards of quality.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0660Potential for Harm

Plan the resident's discharge to meet the resident's goals and needs.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0692Actual Harm

Provide enough food/fluids to maintain a resident's health.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0744Potential for Harm

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0761Potential for Harm

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.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0806Potential for Harm

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0838Potential for Harm

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.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0867Potential for Harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0883Potential for Harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0908Potential for Harm

Keep all essential equipment working safely.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0943Potential for Harm

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0944Potential for Harm

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0949Potential for Harm

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0585Potential for Harm

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.

Survey: Dec 11, 2023Corrected: NoCycle: 1
F0677Potential for Harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey: Jun 10, 2024Corrected: NoCycle: 2
F0689Potential for Harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey: Jun 10, 2024Corrected: NoCycle: 2
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Jun 10, 2024Corrected: NoCycle: 2
F0584Potential for Harm

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.

Survey: Aug 25, 2022Corrected: NoCycle: 2
F0600Actual Harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey: Aug 25, 2022Corrected: NoCycle: 2
F0689Potential for Harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey: Aug 25, 2022Corrected: NoCycle: 2
F0744Potential for Harm

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey: Aug 25, 2022Corrected: NoCycle: 2
F0760Potential for Harm

Ensure that residents are free from significant medication errors.

Survey: Aug 25, 2022Corrected: NoCycle: 2
F0812Potential for Harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey: Aug 25, 2022Corrected: NoCycle: 2

+ 17 more deficiencies

Total Fines
$42,860
Number of Fines
3
Payment Denials
0
Total Penalties
3

Penalty History

FineNov 20, 2023
$3,529
FineOct 30, 2023
$8,469
FineDec 11, 2023
$30,862

Staffing hours per resident per day. The black line shows the national average.

Nurse Aide2.53 hrs
National avg: 2.35 hrs
LPN0.48 hrs
National avg: 0.86 hrs
RN0.83 hrs
National avg: 0.68 hrs
Total Nursing3.84 hrs
National avg: 3.89 hrs
Weekend Total3.42 hrs
National avg: 0.00 hrs
Physical Therapist0.05 hrs
National avg: 0.07 hrs
Total Turnover
57.9%
RN Turnover
43.8%
Administrators Left
1

Quality measures as percentages of residents. Lower is better for all measures.

Ownership Type
For profit - Corporation
Recent Change
No

Owners & Managers (8)

NameRoleTypeOwnership %Since
ENDURA HEALTHCARE LLC5% OR GREATER DIRECT OWNERSHIP INTERESTOrganization100%May 24, 2024
THE ENSIGN GROUP INC5% OR GREATER INDIRECT OWNERSHIP INTERESTOrganization100%May 24, 2024
FUENTEZ, JOSEPHOPERATIONAL/MANAGERIAL CONTROLIndividualN/ASep 1, 2024
JORGENSEN, DAVIDCORPORATE DIRECTORIndividualN/AMay 24, 2024
BURNAM, SOONCORPORATE OFFICERIndividualN/AMay 24, 2024
GRAHAM, JOSEPHCORPORATE OFFICERIndividualN/AMay 24, 2024
JORGENSEN, DAVIDCORPORATE OFFICERIndividualN/AMay 24, 2024
SATO, AMICORPORATE OFFICERIndividualN/ASep 9, 2024

Nearby Nursing Homes

All Colorado facilities

Columbine Commons Health and Rehab LLC

Windsor, CO · 60 beds

For profit
Health
Staffing
Quality
1.6 mi

Frequently Asked Questions

What is the CMS rating for Pelican Pointe Health and Rehabilitation Center?▾
Pelican Pointe Health and Rehabilitation Center has an overall CMS rating of 1 out of 5 stars, with a health inspection rating of 1/5, staffing rating of 4/5, and quality measures rating of 3/5. This facility is rated below average.
Has Pelican Pointe Health and Rehabilitation Center had any health inspection violations?▾
Pelican Pointe Health and Rehabilitation Center had 21 deficiency citations in its most recent health inspection (Dec 11, 2023). The facility has been fined a total of $42,860 across 3 fine(s).
What are the staffing levels at Pelican Pointe Health and Rehabilitation Center?▾
Pelican Pointe Health and Rehabilitation Center provides 3.84 total nursing staff hours per resident per day, including 0.83 RN hours, 0.48 LPN hours, and 2.53 nurse aide hours. The total staff turnover rate is 57.9%.
How many beds does Pelican Pointe Health and Rehabilitation Center have?▾
Pelican Pointe Health and Rehabilitation Center has 104 certified beds with an average of 82.8 residents per day, resulting in approximately 80% occupancy. The facility is For profit - Corporation owned and is part of the The Ensign Group chain.
Are there other nursing homes near Pelican Pointe Health and Rehabilitation Center?▾
Yes, there are 1 other nursing home in Windsor, Colorado with an average rating of 3/5. You can compare all facilities on the Windsor nursing homes page.

Part of The Ensign Group

This chain operates 324 facilities. View all →