LIFE BYVardell
LIFE BYVardellNursing Home
Report

TheVardellReport

Pelican Pointe Health and Rehabilitation Center

Skilled nursing facility and nursing facility

710 3Rd St
Windsor, CO 80550

Report Date
Nov 1, 2026
Data Through
Oct 1, 2026
Report ID
VR-CO-065278-2611
← Pelican Pointe Health and Rehabilitation Center, free profile

Life by Vardell Presents

The Vardell Report.Pelican Pointe Health and Rehabilitation Center

The deeper story, beautifully organized. Available records, historical context, and questions worth asking.

Provider Category
Nursing home
Location
Windsor, CO
Record Period
2022–2026
Source Documents
10
Read the report

This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.

01

The Essentials

Summary

Across 8 inspections from August 2022 to July 2026, state surveyors documented 42 findings at Pelican Pointe Health and Rehabilitation Center; 41 have a recorded correction and 1 awaits one; CMS lists 5 enforcement actions in the window.

Inspections
8
2022–2026, complaint and standard
Findings
42
Deficiencies cited by state inspectors
Corrected
41
Of 42 findings, with a recorded correction date
Penalties
5
5 fines; payment not published

Findings by Year

  • Findings
  • Of which, actual harm (level G or above)
2022: 8 findings across 1 inspection; of which, actual harm (level G or above): 1820221 inspection2023: 17 findings across 1 inspection; of which, actual harm (level G or above): 11720231 inspection2024: 3 findings across 1 inspection320241 inspection2025: 4 findings across 2 inspections; of which, actual harm (level G or above): 1420252 inspections2026: 10 findings across 3 inspections; of which, actual harm (level G or above): 1102026*3 inspections2022: 8 findings across 1 inspection; of which, actual harm (level G or above): 1820221 insp.2023: 17 findings across 1 inspection; of which, actual harm (level G or above): 11720231 insp.2024: 3 findings across 1 inspection320241 insp.2025: 4 findings across 2 inspections; of which, actual harm (level G or above): 1420252 insp.2026: 10 findings across 3 inspections; of which, actual harm (level G or above): 1102026*3 insp.

* Partial year, through October 1, 2026.

Findings by year
YearInspectionsFindingsOf which, actual harm (level G or above)
2022181
20231171
2024130
2025241
20263101

What the Record Shows

  • 41 of 42 findings have a recorded correction date.
  • CMS lists 5 enforcement actions in the window: 5 fines totaling $78,577, their payment not published.
  • 6 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
  • The latest standard inspection, January 15, 2026, recorded 6 findings (most serious: Level D).

What to Ask About

Report at a Glance

Facility
Pelican Pointe Health and Rehabilitation Center
Address
710 3Rd St, Windsor, CO 80550
CMS Certification Number
065278
Provider Type
Skilled nursing facility and nursing facility
Certified Beds
104
Ownership
For profit - Corporation
Record Window
August 25, 2022 to October 1, 2026
02

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

  1. 2026

    Complaint investigation

    1 finding

    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for morePast Non-Compliance

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  2. 2026

    Complaint investigation

    3 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Jun 5, 2026
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jun 5, 2026
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 5, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  3. 2026

    Standard health inspection

    6 findings

    • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Feb 7, 2026
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Feb 7, 2026
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Feb 7, 2026
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 7, 2026
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Feb 7, 2026
    • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Feb 7, 2026

    Enforcement Action

    Civil money penalty, $17,010 imposed May 19, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 15, 2026, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  4. 2025

    Complaint investigation

    3 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Aug 8, 2025
    • F839Employ staff that are licensed, certified, or registered in accordance with state laws.Level FNo actual harm, potential for moreCorrected Aug 8, 2025
    • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Aug 8, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  5. 2025

    Complaint investigation

    1 finding

    • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Feb 19, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  6. 2024

    Complaint investigation

    3 findings

    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jun 12, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Jun 11, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 11, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  7. 2023

    Standard health inspection

    17 findings

    The same visit included a complaint investigation.

    • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Dec 29, 2023
    • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level FNo actual harm, potential for moreCorrected Dec 29, 2023
    • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level ENo actual harm, potential for moreCorrected Dec 29, 2023
    • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Dec 29, 2023
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Dec 29, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 29, 2023
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 29, 2023
    • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Dec 29, 2023
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Dec 29, 2023
    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Dec 29, 2023

    Enforcement Action

    Civil money penalty, $30,862 imposed December 11, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 11, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $18,707 imposed July 15, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 11, 2023, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  8. 2022

    Standard health inspection

    8 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Sep 28, 2022
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Sep 28, 2022
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Sep 28, 2022
    • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level ENo actual harm, potential for moreCorrected Sep 28, 2022
    • F584Honor 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.Level DNo actual harm, potential for moreCorrected Sep 28, 2022
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 28, 2022
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Sep 28, 2022
    • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Sep 28, 2022

    Enforcement Action

    Civil money penalty, $8,469 imposed October 30, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 25, 2022, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $3,529 imposed November 20, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 25, 2022, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

03

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

  1. 1

    Infection Control, Cited in Four Inspections

    Inspectors cited F880 in December 2023, June 2024, January 2026 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223242525262626F880 across all 8 inspections, oldest to newest
  2. 2

    Protection From Abuse and Neglect, Cited in Three Inspections

    Inspectors cited F600 in August 2022, December 2023 and July 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223242525262626F600 across all 8 inspections, oldest to newest
  3. 3

    Grievances, Cited in Two Inspections

    Inspectors cited F585 in December 2023 and February 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223242525262626F585 across all 8 inspections, oldest to newest
  4. 4

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in August 2022 and June 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223242525262626F689 across all 8 inspections, oldest to newest
  5. 5

    Citation F744, Cited in Two Inspections

    Inspectors cited F744 in August 2022 and December 2023. The agency describes it this way: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223242525262626F744 across all 8 inspections, oldest to newest
  6. 6

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in August 2022 and May 2026. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223242525262626F760 across all 8 inspections, oldest to newest
  7. 7

    Citation F867, Cited in Two Inspections

    Inspectors cited F867 in December 2023 and July 2025. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223242525262626F867 across all 8 inspections, oldest to newest
  8. 8

    Reporting Suspected Abuse, No Recorded Correction

    F609 was cited in December 2023 and July 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. The most serious was level D (no actual harm, potential for more). The July 2026 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

    2223242525262626F609 across all 8 inspections, oldest to newest
04

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

  1. 01

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in four inspections, most seriously at level F.

  2. 02

    What happened after the abuse or neglect citation, and what changed in training or supervision?

    Protection From Abuse and Neglect: cited in three inspections, most seriously at level J.

  3. 03

    How do we file a grievance, who answers it, and how quickly?

    Grievances: cited in two inspections, most seriously at level D.

  4. 04

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in two inspections, most seriously at level E.

  5. 05

    What changed after F744 was cited, and how do you check it now?

    Citation F744: cited in two inspections, most seriously at level E.

  6. 06

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in two inspections, most seriously at level D.

  7. 07

    What changed after F867 was cited, and how do you check it now?

    Citation F867: cited in two inspections, most seriously at level F.

  8. 08

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in two inspections, most seriously at level D. The July 21, 2026 citation has no recorded correction date.

  9. 09

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

  10. 10

    What led to the 2026 fine, and has it been paid?

    A $17,010 civil money penalty was imposed May 19, 2026. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.

05

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Colorado state survey agency.

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection Aug 25, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection Dec 11, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection Jun 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection Feb 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection Jul 15, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection Jan 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection May 19, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Colorado state survey agency

    Inspection Jul 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Penalties, Provider Data Catalog

    Centers for Medicare & Medicaid Services

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗
  • Provider Information, Provider Data Catalog

    Centers for Medicare & Medicaid Services · 065278

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗

Coverage

Record windowAugust 25, 2022 – October 1, 2026

  • CMS publishes about three inspection cycles; inspections before August 2022 are not in this release.
  • CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite
Allegations screened out by the state before an onsite visit are not published.
Complaint allegations
CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents
Self-reported incidents appear only if they led to an inspection.
Follow-up visits
CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections
Published by CMS separately and not included in this record yet.
Staffing levels and ownership history
Published by CMS separately and not included in this record.
Whether fines were paid
CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.