Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
PELICAN POINTE HEALTH AND REHABILITATION CENTER
WINDSOR, CO · 104 certified beds · Last Life Safety survey January 15, 2026
CMS Certification Number 065278 · first certified June 1990
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
19 citations — more than 58% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 12 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 9 months from now. This facility’s last Life Safety survey was January 2026. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 19 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0584 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 25, 2022 | 1 |
| December 11, 2023 | 6 |
| January 15, 2026 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2026-01-15 |
| E-0036 | Establish emergency prep training and testing. | 1 | 2023-12-11 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-12-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2026-01-15 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 1 | 2026-01-15 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2026-01-15 |
| K-0500 | Meet other general requirements that are deficient. | 1 | 2026-01-15 |
| K-0161 | Use approved construction type or materials. | 1 | 2026-01-15 |
What the citations cover
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Smoke Deficiencies 4
- Services Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Services Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 15, 2026 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | No revisit needed (February 10, 2027) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 9, 2026) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (March 9, 2026) |
| K-0351 | Install an approved automatic sprinkler system. | No revisit needed (August 10, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 20, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | No revisit needed (February 10, 2027) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (March 11, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | No revisit needed |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (February 25, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 6, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 10, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (March 27, 2026) |
December 11, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 29, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (December 29, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (December 29, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 12, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 12, 2024) |
August 25, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.