Safety Report: Pelican Pointe Health and Rehabilitation Center

Windsor, Colorado · Based on official CMS inspection records as of October 1, 2026.

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How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★
Health inspections★★★★★
Staffing★★★★★
Quality measures★★★★★
Long-stay quality★★★★★
Short-stay qualityNo rating

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

1Immediate jeopardy citations (severity J–L)
3Actual harm citations (severity G–I)
8Requirements cited on more than one inspection
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 19, 2026, during a complaint investigation. Facility reported correction by June 5, 2026.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of July 15, 2025, during a complaint investigation. Facility reported correction by August 8, 2025.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
G
Government finding: Provide enough food/fluids to maintain a resident's health.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of December 11, 2023. Facility reported correction by December 29, 2023.
Quality of Life and Care Deficiencies · Tag F692
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of August 25, 2022. Facility reported correction by September 28, 2022.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Citations by topic

7Abuse, neglect & exploitation
6Infection control
3Medications & pharmacy
2Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

Fewer citations in the most recent cycle (10) than in the cycle before (21).

Two cycles ago
1 serious
Prior cycle
2 serious
Most recent cycle
1 serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

RequirementTimes citedInspection dates
Provide and implement an infection prevention and control program. (F880)4May 19, 2026; January 15, 2026; June 10, 2024; December 11, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600)3July 15, 2025; December 11, 2023; August 25, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609)2July 21, 2026; December 11, 2023
Ensure that residents are free from significant medication errors. (F760)2May 19, 2026; August 25, 2022
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (F867)2July 15, 2025; December 11, 2023
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. (F585)2February 4, 2025; December 11, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689)2June 10, 2024; August 25, 2022
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (F744)2December 11, 2023; August 25, 2022

Fines and enforcement

DateTypeAmount / length
May 19, 2026Fine$17,010
July 15, 2025Fine$18,707
December 11, 2023Fine$30,862
November 20, 2023Fine$3,529
October 30, 2023Fine$8,469

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

42 citations across 8 inspection dates.

July 21, 2026 — 1 citation · complaint investigation
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint
May 19, 2026 — 3 citations (includes serious) · complaint investigation
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected June 5, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected June 5, 2026
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected June 5, 2026
January 15, 2026 — 6 citations
D
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F881 · corrected February 7, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected February 7, 2026
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected February 7, 2026
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected February 7, 2026
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected February 7, 2026
D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F605 · corrected February 7, 2026
July 15, 2025 — 3 citations (includes serious) · complaint investigation
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected August 8, 2025
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · complaint · corrected August 8, 2025
F
Employ staff that are licensed, certified, or registered in accordance with state laws.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F839 · complaint · corrected August 8, 2025
February 4, 2025 — 1 citation · complaint investigation
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · complaint · corrected February 19, 2025
June 10, 2024 — 3 citations · complaint investigation
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected June 11, 2024
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 11, 2024
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected June 12, 2024
December 11, 2023 — 17 citations (includes serious)
G
Provide enough food/fluids to maintain a resident's health.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F692 · corrected December 29, 2023
F
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F949 · corrected December 29, 2023
F
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F944 · corrected December 29, 2023
F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
No actual harm, but potential for more than minimal harm · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F943 · corrected December 29, 2023
F
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F908 · corrected December 29, 2023
F
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F883 · corrected December 29, 2023
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected December 29, 2023
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected December 29, 2023
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F838 · corrected December 29, 2023
E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F744 · corrected December 29, 2023
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · corrected December 29, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected December 29, 2023
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · corrected December 29, 2023
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected December 29, 2023
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · corrected December 29, 2023
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected December 29, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · complaint · corrected December 29, 2023
August 25, 2022 — 8 citations (includes serious)
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected September 28, 2022
F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F925 · corrected September 28, 2022
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected September 28, 2022
E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F744 · corrected September 28, 2022
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F849 · corrected September 28, 2022
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected September 28, 2022
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected September 28, 2022
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected September 28, 2022

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare

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