Paonia Care and Rehabilitation Center
1625 Meadowbrook Blvd, Paonia, CO 81428 · Delta County · 60 certified beds · avg 52 residents/day · certified since Mar 1, 1989
Abuse citation flag (CMS)
Part of chain: MADISON CREEK PARTNERS (13 facilities, chain avg rating 3.2★)
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 · Mar 1, 2024 · F-0805
The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 1, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 7, 2025 · F-0603
The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment.
Why it matters: Forced isolation is emotionally harmful and can hide neglect or abuse from view.
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: Sep 2, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 1, 2024 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
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: Mar 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 3, 2022 · 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: Jan 31, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 3, 2022 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
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: Dec 13, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (44)
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 |
|---|---|---|
| Aug 7, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. |
| Aug 7, 2025 | E · Potential for harm, 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. |
| Aug 7, 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. |
| Aug 7, 2025 | D · Potential for harm, one-off | 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. |
| Aug 7, 2025 | 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. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Aug 7, 2025 | 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. |
| Aug 7, 2025 | 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. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Mar 24, 2025 | 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. · from a complaint |
| Mar 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Mar 1, 2024 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Mar 1, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Mar 1, 2024 | F · Potential for harm, facility-wide | 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. |
| Mar 1, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 1, 2024 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Mar 1, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| Mar 1, 2024 | E · Potential for harm, repeated | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. |
| Mar 1, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 1, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Mar 1, 2024 | E · Potential for harm, repeated | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| Mar 1, 2024 | E · Potential for harm, repeated | 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 |
| Mar 1, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 1, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Mar 1, 2024 | E · Potential for harm, repeated | 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. |
| Mar 1, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Mar 1, 2024 | D · Potential for harm, one-off | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. |
| Mar 1, 2024 | 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. |
| Mar 1, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. |
| Mar 1, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Mar 1, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 1, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Mar 1, 2024 | C · Minimal risk, facility-wide | The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss. |
| Nov 3, 2022 | ▲ 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. |
| Nov 3, 2022 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Nov 3, 2022 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Nov 3, 2022 | E · Potential for harm, 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. |
| Nov 3, 2022 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Nov 3, 2022 | E · Potential for harm, repeated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Nov 3, 2022 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Nov 3, 2022 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Nov 3, 2022 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (23 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 9 | 2 | G ▲ |
| 2024 | 23 | 2 | K ▲ |
| 2025 | 12 | 1 | G ▲ |
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)
2 fines totaling $32,619.
| Date | Type | Amount / length |
|---|---|---|
| Aug 7, 2025 | Fine | $12,438 |
| Mar 1, 2024 | Fine | $20,181 |
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) | 3.89 | 3.89 | 3.95 | top 42% in Colorado; top 44% in the U.S. |
| Registered Nurse hours | 1.34 | 0.86 | 0.69 | top 9% in Colorado; top 7% in the U.S. |
| Weekend total nurse staffing | 3.55 | 3.44 | 3.50 | top 37% in Colorado; top 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.69 | 0.61 | 0.48 | top 30% in Colorado; top 16% in the U.S. |
| Total nursing staff turnover (%) | 62.5 | 47.1 | 45.8 | bottom 11% in Colorado; bottom 13% in the U.S. |
| RN turnover (%) | 58.3 | 44.6 | 42.9 | bottom 22% in Colorado; bottom 24% 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 3.00, RN 1.03, weekend 2.73. 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: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Chief Joseph Trail, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/02/2026 |
| Clegg, Michael | Individual | 5% or Greater Indirect Ownership Interest | — | 03/02/2026 |
| Tippet, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/02/2026 |
| White Canyon, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/02/2026 |
| Christensen, Covey | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2016 |
| Christensen, Covey | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2016 |
| Clegg, Michael | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/26/2023 |
| Clegg, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/26/2023 |
| Clegg, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 06/26/2023 |
| Hopkins, Amber | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2021 |
| Hopkins, Amber | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2021 |
| Ikerd, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/02/2026 |
| Ikerd, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/25/2022 |
| Ikerd, John | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2022 |
| Madison Creek Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2016 |
| Madison Creek Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/26/2026 |
| Meilner, Timothy | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2016 |
| Meilner, Timothy | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2016 |
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 handle residents who need modified food textures, and how do you make those meals appetizing?"
- "Under what circumstances, if any, would a resident ever be kept in their room or separated from others?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "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)
No other Medicare-certified nursing homes within 20 miles in the current records.
Facility data as of CMS processing date 2026-08-01. CCN 065251.