Nursing HomeInspections

Pelican Pointe Health and Rehabilitation Center

Nursing home in Windsor, CO

Medicare & Medicaid certified1★ overall (CMS)

Call (970) 686-7474Send a messageMap ↗

Public-record details

Address
710 3rd St, Windsor, CO 80550
Phone
(970) 686-7474
Listed under
For-profit
Medicare CCN
065278
Overall star rating
1 of 5 ★☆☆☆☆
Health inspection rating
1 of 5
Staffing rating
4 of 5
Quality measures rating
3 of 5
Certified beds
104
Average residents per day
86
Ownership
For-profit, corporation
Legal business name
Belmont Ridge Healthcare INC
Chain
The Ensign Group (342 facilities)
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
Jun 1, 1990
Changed ownership in last 12 months
No
Continuing care retirement community
No
Located inside a hospital
No
Resident or family council
Resident and family councils
Sprinklers in all required areas
Yes

CMS certification number 065278. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Jan 15, 2026. CMS lists 43 health citations for this facility across its last three standard inspection cycles and complaint inspections (Aug 25, 2022 to May 19, 2026): 13 from complaint inspections, 4 at the “actual harm” level or higher, including 1 at “immediate jeopardy”.

InspectionCitationSeverity
May 19, 2026Ensure that residents are free from significant medication errors.
Pharmacy Service · complaint inspection		D
Potential for more than minimal harm, isolated
May 19, 2026Provide and implement an infection prevention and control program.
Infection Control · complaint inspection		D
Potential for more than minimal harm, isolated
May 19, 2026Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care · complaint inspection		G
Actual harm, isolated
Jan 15, 2026Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation		D
Potential for more than minimal harm, isolated
Jan 15, 2026Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning		D
Potential for more than minimal harm, isolated
Jan 15, 2026Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jan 15, 2026Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jan 15, 2026Provide and implement an infection prevention and control program.
Infection Control		D
Potential for more than minimal harm, isolated
Jan 15, 2026Implement a program that monitors antibiotic use.
Infection Control		D
Potential for more than minimal harm, isolated
Jul 15, 2025Employ staff that are licensed, certified, or registered in accordance with state laws.
Administration · complaint inspection		F
Potential for more than minimal harm, widespread
Jul 15, 2025Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration · complaint inspection		F
Potential for more than minimal harm, widespread
Jul 15, 2025Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation · complaint inspection		J
Immediate jeopardy, isolated

Showing the 12 most recent of 43. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records 4 fines totalling $71,640 in the last three years.

Jul 15, 2025Fine: $28,780
Dec 11, 2023Fine: $30,862
Nov 20, 2023Fine: $3,529
Oct 30, 2023Fine: $8,469

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day
3.33 hours
Registered nurse (RN) time per resident per day
0.84 hours
Nurse aide time per resident per day
2.12 hours
Total nurse staffing on weekends
2.97 hours
Nursing staff turnover (yearly)
54%
RN turnover (yearly)
32%
Administrators who left in the past year
1

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.

Other nursing homes in Windsor

Columbine Commons Health and Rehab LLC1475 Main St · Windsor, CO 80550 · (970) 449-5540 · For-profit7 health citations in 3 inspection cycles · last standard inspection Apr 17, 2025 · no CMS fines in 3 yrsMedicare-certified5★ overall (CMS)

All 2 in Windsor →