D
46/100PELICAN POINTE HEALTH AND REHABILITATION CENTER Inspection Report, Violations & Safety Grade (WINDSOR, Colorado)
710 3RD ST, WINDSOR, Colorado 80550
Phone: 9706867474
CMS Overall:2/5
Overview & Bed Count
Certified Beds
104
Avg Residents/Day
88.9
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Weld
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health1/5
Staffing3/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Colorado Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.78 | 0.81 | -0.04 |
| Total Nurse Hours per Resident per Day | 3.36 | 3.69 | -0.33 |
| CMS Staffing Rating | 3/5 | 3.1/5 | - |
| Nursing Staff Turnover | 63.1% | 47% | - |
Health Citation History
42 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-21 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-05-19 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2026-05-19 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2026-05-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-01-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2026-01-15 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2026-01-15 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2026-01-15 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-01-15 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-01-15 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | D – Moderate Harm Potential |
| 2025-07-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J – Immediate Jeopardy |
| 2025-07-15 | Administration Deficiencies | Employ staff that are licensed, certified, or registered in accordance with state laws. | F – Moderate Harm Potential |
| 2025-07-15 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2025-02-04 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-06-10 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2024-06-10 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2024-06-10 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2023-12-11 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | G – Actual Harm |
| 2023-12-11 | Administration Deficiencies | 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. | F – Moderate Harm Potential |
| 2023-12-11 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2023-12-11 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-12-11 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | F – Moderate Harm Potential |
| 2023-12-11 | Environmental Deficiencies | Keep all essential equipment working safely. | F – Moderate Harm Potential |
| 2023-12-11 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | F – Moderate Harm Potential |
| 2023-12-11 | Administration Deficiencies | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | F – Moderate Harm Potential |
| 2023-12-11 | Administration Deficiencies | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | F – Moderate Harm Potential |
| 2023-12-11 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E – Moderate Harm Potential |
| 2023-12-11 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-12-11 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2023-12-11 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2023-12-11 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2023-12-11 | Resident Assessment and Care Planning Deficiencies | Plan the resident's discharge to meet the resident's goals and needs. | D – Moderate Harm Potential |
| 2023-12-11 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-12-11 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2022-08-25 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2022-08-25 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2022-08-25 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F – Moderate Harm Potential |
| 2022-08-25 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E – Moderate Harm Potential |
| 2022-08-25 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2022-08-25 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2022-08-25 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2022-08-25 | Administration Deficiencies | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
19 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-15 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2026-01-15 | Smoke Deficiencies | Install an approved automatic sprinkler system. | F – Moderate Harm Potential |
| 2026-01-15 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-01-15 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2026-01-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2026-01-15 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2026-01-15 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2026-01-15 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2026-01-15 | Services Deficiencies | Meet other general requirements that are deficient. | E – Moderate Harm Potential |
| 2026-01-15 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | E – Moderate Harm Potential |
| 2026-01-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2026-01-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | E – Moderate Harm Potential |
| 2023-12-11 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2023-12-11 | Emergency Preparedness Deficiencies | Develop a communication plan. | F – Moderate Harm Potential |
| 2023-12-11 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | F – Moderate Harm Potential |
| 2023-12-11 | Emergency Preparedness Deficiencies | Establish staff and initial training requirements. | F – Moderate Harm Potential |
| 2023-12-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2023-12-11 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
| 2022-08-25 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
Total Penalties & Fines
$78,577
Total Fine Amount (CMS)
5
Number of Fines
5
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-05-19 | Fine | $17,010 | - |
| 2025-07-15 | Fine | $18,707 | - |
| 2023-12-11 | Fine | $30,862 | - |
| 2023-11-20 | Fine | $3,529 | - |
| 2023-10-30 | Fine | $8,469 | - |
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WINDSOR area at no cost.
Find Safe, Vetted Facilities Near WINDSOR
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WINDSOR area at no cost.
Find Safe, Vetted Facilities Near WINDSOR
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.