Bruce McCandless Co State Veterans Nursing Home
903 Moore Dr, Florence, CO 81226 · Fremont County · 105 certified beds · avg 61 residents/day · certified since Oct 1, 2008
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jan 29, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 26, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 6, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 25, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 27, 2020 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 13, 2020 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 27, 2020 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 13, 2020 (Deficient, Provider has date of correction)
All citations in the current public record (20)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 29, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 29, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 6, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Feb 27, 2020 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 27, 2020 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 27, 2020 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 27, 2020 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 27, 2020 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 27, 2020 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 27, 2020 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 27, 2020 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Feb 27, 2020 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2020 | 9 | 2 | G ▲ |
| 2024 | 6 | 1 | G ▲ |
| 2026 | 5 | 1 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $52,988.
| Date | Type | Amount / length |
|---|---|---|
| Jan 29, 2026 | Fine | $52,988 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.76 | 3.89 | 3.95 | top 14% in Colorado; top 17% in the U.S. |
| Registered Nurse hours | 2.34 | 0.86 | 0.69 | top 1% in Colorado; top 1% in the U.S. |
| Weekend total nurse staffing | 4.09 | 3.44 | 3.50 | top 15% in Colorado; top 20% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.56 | 0.61 | 0.48 | top 2% in Colorado; top 2% in the U.S. |
| Total nursing staff turnover (%) | 60.0 | 47.1 | 45.8 | bottom 17% in Colorado; bottom 17% in the U.S. |
| RN turnover (%) | 58.8 | 44.6 | 42.9 | bottom 20% in Colorado; bottom 23% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.77, RN 1.86, weekend 3.24. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Government - State
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| State of Colorado | Organization | 5% or Greater Direct Ownership Interest | 100% | 11/01/1975 |
| Cowan, Jesse | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Cowan, Jesse | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Hsu, Carrie | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Hsu, Carrie | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Moore, Barbara | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2006 |
| Moore, Barbara | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Moore, Barbara | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Hildebrand Care Center | 8.3 mi | Canon City, CO | ★★★★★ | 4/5 | |
| Progressive Care Center | 8.3 mi | Canon City, CO | ★★☆☆☆ | 2/5 | abuse |
| Skyline Ridge Nursing & Rehabilitation Center | 8.6 mi | Canon City, CO | ★★☆☆☆ | 2/5 | abuse |
| Valley View Care Center | 8.9 mi | Canon City, CO | ★★★☆☆ | 2/5 | |
| Canon Lodge Care Center | 8.9 mi | Canon City, CO | ★★☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 065394.