The nursing home failed to protect residents from abuse and neglect by others. Cited July 2025 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 600 — 42 CFR §483.12 — S/S: J
Nursing home report
Pelican Pointe Health and Rehabilitation
Registered name: PELICAN POINTE HEALTH AND REHABILITATION CENTER
WINDSOR, CO · Medicare-certified · 104 beds
Needs attention
Abuse citationFor-profitChain member
Data as of July 1, 2026
1 of 5 overall
Pelican Pointe Health and Rehabilitation in Windsor, CO has a 1-star overall rating, with a 1-star health inspection rating and a recent abuse citation. Staffing is rated 4 stars, but reported nurse staffing is 3.33 hours per resident per day, below the 4.1-hour federal benchmark; the facility also had $28,780 in fines in the last 24 months.
Facility ratings
Health inspections
Staffing
3.3252 hrs/resident/day
Quality measures
Last inspection: May 19, 2026Penalties, last 24 months: $28,780recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.3252.
Staffing detail
- Registered nurses
- 0.84
- Licensed practical nurses
- 0.36
- Nurse aides
- 2.12
- Weekend nursing
- 2.97
Hours per resident per day.
Total staff turnover: 54%
Registered nurse turnover: 32%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
42.3%38.8%Improving
Residents with a fall causing major injury
5%5.3%No change
Residents with pressure ulcers (bedsores)
4.2%4%No change
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
10%7.5%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
16.1%9.4%Improving
Residents whose ability to walk got worse
23%10.3%Improving
Long-stay residents on antianxiety or sleep medication
7.1%5.9%Improving
Short-stay residents newly given an antipsychotic
—3.1%—
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
37%21.1%Improving
Residents with depressive symptoms
2.9%5.1%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—93.7%—
Long-stay residents given the pneumonia vaccine
95%97.3%Improving
Short-stay residents given the seasonal flu vaccine
—65.9%—
Short-stay residents given the pneumonia vaccine
74.5%47.6%Worsening
What the inspectors found
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited May 2026 — isolated incident, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: G
The home failed to provide enough food and fluids to keep residents healthy. Cited December 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 692 — 42 CFR §483.25(g) — S/S: G
The home failed to ensure its staff were properly licensed, certified, or registered as required by state law. Cited July 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 839 — 42 CFR §483.70 — S/S: F
The home failed to have an ongoing quality review group that finds problems and makes corrective plans. Cited July 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 867 — 42 CFR §483.75 — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 6 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $28,780 was recorded.
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Penalties & enforcement
On record with Medicare: 4 fines · $71,640 in total fines.
- $28,780
Federal fine
Jul 15, 2025
- $30,862
Federal fine
Dec 11, 2023
- $3,529
Federal fine
Nov 20, 2023
- $8,469
Federal fine
Oct 30, 2023
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of THE ENSIGN GROUP · 346 homes · 3.2 stars avg
- Occupancy
- 85.5 residents on an average day (82% of 104 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 36 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.