Hildebrand Care Center
1401 Phay Ave, Canon City, CO 81212 · Fremont County · 75 certified beds · avg 70 residents/day · certified since Oct 18, 1983
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
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, one-off · Apr 17, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 6, 2024 (Past Non-Compliance)
All citations in the current public record (13)
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 |
|---|---|---|
| Dec 4, 2025 | 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. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Dec 4, 2025 | D · Potential for 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. · from a complaint |
| Apr 17, 2024 | ▲ J · Immediate jeopardy, 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. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Nov 16, 2023 | D · Potential for 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. |
| Nov 16, 2023 | 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. |
| Nov 16, 2023 | D · Potential for harm, one-off | 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. |
| Jul 28, 2022 | F · Potential for harm, facility-wide | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Jul 28, 2022 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jul 28, 2022 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 3 | 0 | F |
| 2023 | 6 | 0 | D |
| 2024 | 1 | 1 | J ▲ |
| 2025 | 3 | 0 | E |
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 $15,642.
| Date | Type | Amount / length |
|---|---|---|
| Apr 17, 2024 | Fine | $15,642 |
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) | 4.44 | 3.89 | 3.95 | top 23% in Colorado; top 25% in the U.S. |
| Registered Nurse hours | 1.22 | 0.86 | 0.69 | top 15% in Colorado; top 9% in the U.S. |
| Weekend total nurse staffing | 3.89 | 3.44 | 3.50 | top 23% in Colorado; top 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.78 | 0.61 | 0.48 | top 22% in Colorado; top 12% in the U.S. |
| Total nursing staff turnover (%) | 48.6 | 47.1 | 45.8 | bottom 45% in Colorado; bottom 40% in the U.S. |
| RN turnover (%) | 57.1 | 44.6 | 42.9 | bottom 24% in Colorado; bottom 26% 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 3.81, RN 1.05, weekend 3.34. 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: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Beaton, Kimberly | Individual | 5% or Greater Direct Ownership Interest | — | 08/01/2017 |
| Leonard, Sharon | Individual | 5% or Greater Direct Ownership Interest | — | 08/01/2017 |
| Shadow Mountain Management | Organization | 5% or Greater Direct Ownership Interest | — | 11/01/1973 |
| Cory, Phillip | Individual | Corporate Director | NOT APPLICABLE | 01/01/2010 |
| Hamby, Robert | Individual | Corporate Director | NOT APPLICABLE | 01/01/2010 |
| Lester, Delwin | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/31/2018 |
| Shadow Mountain Management | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/2016 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "How do you arrange eye and hearing care for residents, including appointments and equipment like glasses or hearing aids?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "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 |
|---|---|---|---|---|---|
| Progressive Care Center | 0.0 mi | Canon City, CO | ★★☆☆☆ | 2/5 | abuse |
| Skyline Ridge Nursing & Rehabilitation Center | 0.6 mi | Canon City, CO | ★★☆☆☆ | 2/5 | abuse |
| Valley View Care Center | 0.6 mi | Canon City, CO | ★★★☆☆ | 2/5 | |
| Canon Lodge Care Center | 0.6 mi | Canon City, CO | ★★☆☆☆ | 2/5 | abuse |
| Bruce McCandless Co State Veterans Nursing Home | 8.3 mi | Florence, CO | ★☆☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 065179.