Pioneer Health Care Center
900 S 12th St, Rocky Ford, CO 81067 · Otero County · 101 certified beds · avg 78 residents/day · certified since Feb 1, 1987
Part of chain: MADISON CREEK PARTNERS (13 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
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)
▲ Actual harm, one-off · Apr 18, 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: Apr 2, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Sep 16, 2021 · F-0600
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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 11, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 16, 2021 · F-0684
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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 11, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 16, 2021 · F-0744
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.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
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: Oct 11, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (24)
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 |
|---|---|---|
| Mar 4, 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 |
| Aug 29, 2024 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Aug 29, 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. · from a complaint |
| Aug 29, 2024 | 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. · from a complaint |
| Apr 18, 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. |
| Apr 18, 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. |
| Apr 18, 2024 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Apr 18, 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. · from a complaint |
| Apr 18, 2024 | 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. |
| Apr 18, 2024 | 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. |
| Nov 13, 2023 | 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. · from a complaint |
| Dec 29, 2022 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Dec 29, 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. |
| Dec 29, 2022 | E · Potential for harm, repeated | The facility did not perform required COVID-19 testing on residents and staff. |
| Sep 16, 2021 | ▲ G · Actual 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. |
| Sep 16, 2021 | ▲ G · Actual 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. |
| Sep 16, 2021 | ▲ G · Actual harm, one-off | 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. |
| Sep 16, 2021 | F · Potential for harm, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Sep 16, 2021 | 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. |
| Sep 16, 2021 | D · Potential for harm, one-off | 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. |
| Sep 16, 2021 | 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. |
| Sep 16, 2021 | 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. |
| Sep 16, 2021 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 9 | 3 | G ▲ |
| 2022 | 3 | 0 | E |
| 2023 | 1 | 0 | E |
| 2024 | 10 | 1 | G ▲ |
| 2025 | 1 | 0 | D |
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 $10,033.
| Date | Type | Amount / length |
|---|---|---|
| Apr 18, 2024 | Fine | $10,033 |
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) | 4.45 | 3.89 | 3.95 | top 22% in Colorado; top 24% in the U.S. |
| Registered Nurse hours | 0.75 | 0.86 | 0.69 | bottom 44% in Colorado; top 32% in the U.S. |
| Weekend total nurse staffing | 3.99 | 3.44 | 3.50 | top 19% in Colorado; top 23% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.61 | 0.48 | bottom 26% in Colorado; top 45% in the U.S. |
| Total nursing staff turnover (%) | 44.0 | 47.1 | 45.8 | top 41% in Colorado; top 47% in the U.S. |
| RN turnover (%) | 46.7 | 44.6 | 42.9 | bottom 45% in Colorado; bottom 41% 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 3.36, RN 0.56, weekend 3.02. 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 - 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 |
| Cook, Cameron | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/27/2025 |
| Cook, Cameron | Individual | ADP of the SNF | NOT APPLICABLE | 02/27/2025 |
| 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 | 03/30/2026 |
| Shepherd, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2022 |
| Shepherd, David | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "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?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "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 |
|---|---|---|---|---|---|
| Crowley County Nursing Center | 12.1 mi | Ordway, CO | ★★★★☆ | 3/5 | |
| Bluestem Village | 15.9 mi | La Junta, CO | —/5 | ||
| Fowler Health Care | 17.3 mi | Fowler, CO | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
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Facility data as of CMS processing date 2026-08-01. CCN 065235.