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 CENTER
WINDSOR, CO · Medicare-certified · 104 beds
Needs attention
Abuse citationFor-profitChain member
1 of 5 overall
Pelican Pointe Health and Rehabilitation Center 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 3.41 hours per resident per day, below the 4.1-hour federal benchmark; there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
3.4137 hrs/resident/day
Quality measures
Last inspection: January 15, 2026Penalties, last 24 months: $0recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.4137.
Staffing detail
- Registered nurses
- 0.83
- Licensed practical nurses
- 0.44
- Nurse aides
- 2.14
- Weekend nursing
- 3.02
Hours per resident per day.
Total staff turnover: 59%
Registered nurse turnover: 42%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
38.3%Worsening
Residents with a fall causing major injury
4.7%Worsening
Residents with pressure ulcers (bedsores)
4.3%Worsening
Residents with a urinary tract infection
1.9%Worsening
Residents who lost too much weight
9.2%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
21.5%Improving
Residents whose ability to walk got worse
24.4%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
6.9%Improving
Short-stay residents newly given an antipsychotic
3.4%Steady
Residents with a long-term catheter
0.4%Improving
Residents with new or worsening incontinence
30.1%Improving
Residents with depressive symptoms
2.7%Improving
Long-stay residents given the seasonal flu vaccine
93.7%Steady
Long-stay residents given the pneumonia vaccine
95.6%Improving
Short-stay residents given the seasonal flu vaccine
65.9%Steady
Short-stay residents given the pneumonia vaccine
63.6%Worsening
What the inspectors found
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.
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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.
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F-Tag 867 — 42 CFR §483.75 — S/S: F
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited December 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — 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 6 health deficiencies.
See what inspectors found
- 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: 3 fines · $42,860 in total fines.
- $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 · 338 homes · 3.2 stars avg
- Occupancy
- 84.8 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.