Paonia Care and Rehabilitation Center
1625 Meadowbrook Blvd · Paonia, CO · 81428 · 9705274837
60 certified beds For profit - Limited Liability company Chain: Madison Creek Partners
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- 4 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Total nurse staffing below 3.0 hours per resident-day
2.93 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
68% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 2.93 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.73 | 0.55–0.75 |
| Weekend hours / resident-day | 2.61 | ≈ weekday level |
| Nursing turnover / year | 68% | median 45% |
| Fines (3-yr window) | 2 · $32,619 |
Inspection citations (44 in the current record)
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Actual harm · G August 7, 2025
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected September 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 7, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 7, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected September 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 7, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 2, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected September 2, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected September 2, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected September 2, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025
Provide and implement an infection prevention and control program.
Corrected September 2, 2025 · Infection Control
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Potential for harm · D August 7, 2025
Implement a program that monitors antibiotic use.
Corrected September 2, 2025 · Infection Control
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Potential for harm · D August 7, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected September 2, 2025 · Infection Control
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Potential for harm · D August 7, 2025
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected September 2, 2025 · Infection Control
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Potential for harm · D March 24, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K March 1, 2024
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected March 1, 2024 · Nutrition and Dietary
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Actual harm · G March 1, 2024 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected March 28, 2024 · Quality of Life and Care
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Potential for harm · D March 1, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected March 28, 2024 · Resident Rights
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Potential for harm · E March 1, 2024
Honor the resident's right to manage his or her financial affairs.
Corrected March 28, 2024 · Resident Rights
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Potential for harm · E March 1, 2024
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected March 28, 2024 · Resident Rights
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Potential for harm · E March 1, 2024
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.
Corrected March 28, 2024 · Resident Rights
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Potential for harm · D March 1, 2024
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected March 28, 2024 · Resident Rights
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Potential for harm · D March 1, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 28, 2024 · Resident Assessment and Care Planning
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Potential for harm · D March 1, 2024
Plan the resident's discharge to meet the resident's goals and needs.
Corrected March 28, 2024 · Resident Assessment and Care Planning
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Potential for harm · D March 1, 2024
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected March 28, 2024 · Quality of Life and Care
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Potential for harm · E March 1, 2024
Ensure the activities program is directed by a qualified professional.
Corrected March 28, 2024 · Quality of Life and Care
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Potential for harm · E March 1, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected March 28, 2024 · Pharmacy Service
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Potential for harm · D March 1, 2024
Ensure that residents are free from significant medication errors.
Corrected March 28, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 7, 2025 | Fine | $12,438 |
| March 1, 2024 | Fine | $20,181 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 065251 · certified since March 1, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.