Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paonia Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was not protected from being separated from others or confined to their room, indicating a failure by staff to uphold resident rights regarding social interaction and movement within the facility.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
A resident with significant care needs was not provided with timely assistance for repositioning or toileting, resulting in her remaining in bed for nearly four hours without incontinence care. Despite care plan directives and staff acknowledgment of the need for two-hour checks, the resident was left in a saturated brief until staff responded to her call light.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Staff did not deliver care or services in a manner that was trauma informed or culturally competent, failing to consider residents' trauma histories or cultural backgrounds as required.
The facility did not provide necessary behavioral health care and services to residents, resulting in unmet behavioral health needs.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple medical conditions was started on antibiotics for a UTI without the facility obtaining or documenting culture and sensitivity results prior to administration. Staff interviews revealed there was no specific monitoring or documentation process for antibiotic use, and the facility did not follow up with the hospital for necessary test results to ensure appropriate antibiotic selection.
The facility did not establish or follow required policies and procedures for administering flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
Two residents with significant medical histories were not offered the COVID-19 vaccine as required by facility policy and CDC guidelines. Interviews and record reviews confirmed that neither resident was offered the vaccine, and there was no documentation of vaccine administration or refusal in their EMRs, reflecting a failure in the facility's immunization procedures.
The facility failed to protect two residents from sexual abuse by another resident, leading to a deficiency in ensuring resident safety. The first incident involved a non-verbal resident with severe cognitive impairment, who was not provided with new interventions to prevent future occurrences. The assailant, with a history of inappropriate behaviors, was inadequately monitored, and his care plan was not updated until after a second incident occurred with another resident. Inconsistencies in staff understanding and implementation of supervision protocols contributed to the facility's failure to protect residents.
Failure to Prevent Resident Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from separation from other residents, their room, or confinement to their room. The report notes that residents were not adequately safeguarded against being isolated or separated, which is a violation of their rights. Specific actions or inactions by staff that led to this deficiency are not detailed in the report, nor are there descriptions of the circumstances or conditions of the residents involved at the time of the incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, who had diagnoses including acute respiratory failure, irritable bowel syndrome, osteoarthritis, and a history of pneumonia, required substantial to maximal staff assistance for transfers and toileting, as documented in her care plan and MDS assessment. Despite this, observations showed that the resident was not offered repositioning or toileting assistance for a period of nearly four hours. During this time, the resident remained in bed and was not checked by staff, even when visited by the nursing home administrator, who did not inquire about her need for repositioning or toileting. The resident reported that she needed to be checked every two hours for toileting assistance but stated that staff did not check on her, leading her to limit her fluid intake. Continuous observation confirmed that the resident was not provided incontinence care from 12:30 p.m. to 4:12 p.m., and when staff finally responded to her call light, her brief was found to be saturated with urine. Staff interviews confirmed that residents requiring assistance should be checked every two hours, and failure to do so could result in negative outcomes. The care plan also indicated the need for staff assistance with repositioning, which was not provided during the observed period.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received the necessary respiratory care as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or address the trauma histories or cultural backgrounds of residents when delivering care or services, as required. The report does not specify particular residents or detail specific incidents, but it documents the lack of trauma-informed and culturally competent approaches in the care provided.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and findings that the required behavioral health interventions and supports were not provided to residents as needed. The report documents that the facility did not meet the obligation to assess, plan, or deliver appropriate behavioral health care, resulting in unmet behavioral health needs among residents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Monitor and Document Antibiotic Use Prior to Administration
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship program that ensures appropriate use and monitoring of antibiotics. Specifically, for one resident, the facility did not ensure that clinical signs and symptoms of infection were identified and that culture results were obtained prior to the administration of antibiotics. The resident, who had a history of congestive heart failure, anemia, hypertension, benign prostate hyperplasia, obstructive uropathy, and asthma, was admitted with a urinary catheter and was cognitively intact. The resident was prescribed an antibiotic for a urinary tract infection (UTI) following a hospital visit, where a urinalysis indicated a UTI and a culture and sensitivity was ordered. However, there was no documentation in the resident's medical record to show that the culture and sensitivity was completed or that the results were obtained before starting antibiotic therapy. Staff interviews revealed a lack of specific monitoring or documentation for residents on antibiotics, and the infection preventionist acknowledged that the facility did not follow up with the hospital for the culture results. The director of nursing also confirmed that the facility did not receive or pursue the culture and sensitivity results, which are necessary to determine the most effective antibiotic treatment.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Offer and Document COVID-19 Vaccination for Two Residents
Penalty
Summary
The facility failed to implement its policies and procedures regarding COVID-19 immunizations for two of five residents reviewed for immunizations. Specifically, the facility did not offer the COVID-19 vaccine to two residents, as required by both CDC guidelines and the facility's own policy. Both residents had medical histories that placed them at risk, including conditions such as atrial fibrillation, lymphedema, hypertension, chronic osteomyelitis, diabetes, and cirrhosis. Despite these risk factors, there was no documentation in their electronic medical records indicating that the COVID-19 vaccine was offered or administered, nor was there documentation of vaccine refusal. Interviews with the residents confirmed that they had not been offered any vaccinations during their stay at the facility. The DON stated that it was the responsibility of the admitting nurse to offer and document vaccinations, and that refusals or administrations should be recorded in the EMR. However, the facility was unable to provide documentation to support that the vaccine was offered or refused for these residents, indicating a failure to follow established procedures for COVID-19 immunization assessment, education, and documentation.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, leading to a deficiency in ensuring resident safety. The first incident involved a resident with severe cognitive impairment who was non-verbal and dependent on staff for all activities of daily living. This resident was found with another resident's hand inside her shirt, but no new interventions were implemented in her care plan to prevent future occurrences. The facility's investigation confirmed the physical contact but did not document any changes in the victim's care plan or monitoring for behavioral changes following the incident. The assailant, a resident with severe cognitive impairments and a history of inappropriate sexual behaviors, was not adequately monitored or supervised following the first incident. Despite being placed on one-to-one supervision, there was no documentation or physician's order to confirm this action. The resident's behavior care plan was not updated with new interventions until over two months later, after a second incident occurred with another resident. The facility's failure to consistently document and implement effective monitoring and supervision measures contributed to the recurrence of inappropriate behaviors. The second incident involved a cognitively intact resident who was touched inappropriately by the same assailant. Although the facility conducted an investigation and added new interventions to the assailant's care plan, the initial lack of effective interventions and monitoring allowed the incident to occur. Staff interviews revealed inconsistencies in the understanding and implementation of supervision protocols, further highlighting the facility's failure to protect residents from abuse.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paonia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Horizons Care Center | 21.7 mi | — | 1 | 0 |
| Willow Tree Care Center | 27.7 mi | — | 14 | 0 |
| Colorow Care Center | 27.8 mi | — | 2 | 0 |
| Hope Springs Care Center | 30.7 mi | — | 0 | 0 |
| Valley Manor Care Center | 31.2 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.