Pelican Pointe Health And Rehabilitation Center has received an F grade based on CMS data, with a score of 19/100 — placing it among the lowest-rated nursing facilities in Colorado. Families considering this Windsor facility should carefully review its inspection history and quality metrics.
Staffing at Pelican Pointe Health And Rehabilitation Center is near the national average, with 3.84 total nursing hours per resident per day (national average: 3.8 hours).
Recent CMS inspections identified 47 deficiencies at Pelican Pointe Health And Rehabilitation Center, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.84 | 3.8 | Average |
| Registered Nurses (RN) | 0.83 | 0.7 | Above Average |
| Licensed Practical Nurses (LPN) | 0.48 | 0.7 | Below Average |
| Certified Nursing Assistants (CNA) | 2.53 | 2.4 | Average |
| Weekend Total Nursing | 3.42 | 3.8 | Below Average |
| Weekend RN Hours | 0.51 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0600 Severity JProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Jul 14, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0839 Severity FEmploy staff that are licensed, certified, or registered in accordance with state laws.Jul 14, 2025 · Administration Deficiencies
- Tag 0867 Severity FSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Jul 14, 2025 · Administration Deficiencies
- Tag 0585 Severity DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt eFeb 3, 2025 · Resident Rights Deficiencies
- Tag 0677 Severity EProvide care and assistance to perform activities of daily living for any resident who is unable.Jun 9, 2024 · Quality of Life and Care Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 3.2% | 4.5% | Better |
| Falls with major injury | 4.3% | 3.0% | Worse |
| On antipsychotic medication | 40.5% | 14.5% | Worse |
| Urinary tract infections | 0.6% | 2.5% | Better |
| ADL decline (daily activities) | 34.2% | 14.0% | Worse |
| Excessive weight loss | 8.8% | 7.5% | Worse |
| New/worsened incontinence | 32.8% | 45.0% | Better |
⚠️ Penalties & Fines
3 penalties recorded by CMS
Total fines: $42,860
How This Grade Was Calculated
This facility's grade of F is based on a score of 19 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 1★ → 8 pts (max 40)
- Health Inspection Rating: 1★ → 5 pts (max 25)
- Staffing Rating: 4★ → 16 pts (max 20)
- Quality Measures Rating: 3★ → 9 pts (max 15)
- Penalty deductions: -15 pts
- Fine deductions: -4 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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