Paonia Care And Rehabilitation Center
Paonia, Delta County, Colorado · CCN 065251 · For-profit (LLC) · part of Madison Creek Partners (13 facilities, chain average 3.2 stars)
CMS rates Paonia Care And Rehabilitation Center 1 of 5 overall as of August 2026. 60 certified beds, 52 residents a day on average. 44 citations on record from the current inspection cycles, 1 at immediate jeopardy; 2 fines totalling $32,619.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 4 / — of 5 |
Staffing
| Total nurse staffing | 2.99839 hours per resident per day |
|---|---|
| Registered nurses | 1.03036 hours per resident per day |
| Weekend total | 2.73172 hours per resident per day |
| Nursing staff turnover | 62.5% (registered nurses 58.3%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-08-07 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0603 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · tag F0740 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · tag F0881 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-08-07 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · tag F0887 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-02 |
| 2025-03-24 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2024-03-01 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2024-03-01 |
| 2024-03-01 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · tag F0801 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · tag F0803 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · tag F0867 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-03-30 |
| 2024-03-01 | Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · tag F0567 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Resident Rights Deficiencies · tag F0569 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 complaint survey |
Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · tag F0680 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 complaint survey |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · tag F0626 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · tag F0660 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-28 |
| 2024-03-01 | The resident has the right to receive notices in a format and a language he or she understands. Resident Rights Deficiencies · tag F0574 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has plan of correction 2024-03-28 |
| 2022-11-03 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-01-31 |
| 2022-11-03 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2022-12-13 |
| 2022-11-03 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · tag F0867 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2022-12-13 |
| 2022-11-03 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-13 |
| 2022-11-03 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-13 |
| 2022-11-03 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-13 |
| 2022-11-03 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-13 |
| 2022-11-03 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-13 |
| 2022-11-03 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · tag F0825 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-01-31 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-08-07 | Fine | $12,438 |
| 2024-03-01 | Fine | $20,181 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Chief Joseph Trail, LLC Organization | 5% or greater direct ownership interest | 100% | 2026-03-02 |
| Tippet, LLC Organization | 5% or greater indirect ownership interest | — | 2026-03-02 |
| White Canyon, LLC Organization | 5% or greater indirect ownership interest | — | 2026-03-02 |
| Madison Creek Partners LLC Organization | adp of the snf | — | 2026-03-26 |
| Madison Creek Partners LLC Organization | operational/managerial control | — | 2016-07-01 |
| Clegg, Michael Individual | 5% or greater indirect ownership interest | — | 2026-03-02 |
| Christensen, Covey Individual | adp of the snf | — | 2016-07-01 |
| Clegg, Michael Individual | adp of the snf | — | 2023-06-26 |
| Hopkins, Amber Individual | adp of the snf | — | 2021-12-01 |
| Ikerd, John Individual | adp of the snf | — | 2022-04-25 |
| Meilner, Timothy Individual | adp of the snf | — | 2016-07-01 |
| Clegg, Michael Individual | managing control - governing body | — | 2023-06-26 |
| Ikerd, John Individual | managing control - governing body | — | 2026-03-02 |
| Christensen, Covey Individual | operational/managerial control | — | 2016-07-01 |
| Clegg, Michael Individual | operational/managerial control | — | 2023-06-26 |
| Hopkins, Amber Individual | operational/managerial control | — | 2021-12-01 |
| Ikerd, John Individual | operational/managerial control | — | 2022-04-25 |
| Meilner, Timothy Individual | operational/managerial control | — | 2016-07-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Paonia Care And Rehabilitation Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Delta County.