Map showing the location of PAONIA CARE AND REHABILITATION CENTER in PAONIA, Colorado
1625 MEADOWBROOK BLVD, PAONIA, CO, 81428

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • ColoradoAbove only 14% of peers208 rated homes · average 3.1★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.7 vs CO avg
  • StaffingCan add or remove a star3★−0.1 vs CO avg
  • Quality measuresCan add or remove a star5★+0.8 vs CO avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCO avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 31% of peersCO avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 50% of peersCO avg4.2★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff2.95hrsAbove only 7% of peersCO avg3.73Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.76hrsAbove only 48% of peersCO avg0.83Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better74%Above only 3% of peersCO avg49%RN turnover62%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$39,316Above only 22% of peersCO avg$25,587Fines · denials2 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
44citations
4inspection dates
4actual harm (G–I)
1immediate jeopardy (J–L)
Aug 7, 2025most recent

Citations by monthNov 2022 – Aug 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Aug 7, 202511 citationsCycle 1worst G · actual harm$19,135
  1. F887Educate 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 ControlD · isolatedCorrected Sep 2, 2025
  2. F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Sep 2, 2025
  3. F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 2, 2025
  4. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Sep 2, 2025
  5. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Sep 2, 2025
  6. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 2, 2025
  7. F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Sep 2, 2025
  8. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Sep 2, 2025
  9. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 2, 2025
  10. F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Sep 2, 2025
  11. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Sep 2, 2025
Mar 24, 20251 citationCycle 1worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 29, 2025
Mar 1, 202423 citationsCycle 2worst K · immediate jeopardy$20,181
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Mar 28, 2024
  2. F801Employ 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 DietaryF · widespreadCorrected Mar 28, 2024
  3. F803Ensure 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 DietaryF · widespreadCorrected Mar 28, 2024
  4. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryK · patternCorrected Mar 1, 2024
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 28, 2024
  6. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Mar 30, 2024
  7. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 28, 2024
  8. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Mar 28, 2024
  9. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Mar 28, 2024
  10. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Mar 28, 2024
  11. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Mar 28, 2024
  12. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Mar 28, 2024
  13. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Mar 28, 2024
  14. F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Mar 28, 2024
  15. F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Resident RightsE · patternCorrected Mar 28, 2024
  16. F574The resident has the right to receive notices in a format and a language he or she understands.Resident RightsC · widespreadCorrected Mar 28, 2024
  17. F584Honor 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 RightsE · patternCorrected Mar 28, 2024
  18. F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Mar 28, 2024
  19. F656Develop 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 PlanningD · isolatedCorrected Mar 28, 2024
  20. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Mar 28, 2024
  21. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Mar 28, 2024
  22. F680Ensure the activities program is directed by a qualified professional.Quality of Life and CareE · patternCorrected Mar 28, 2024
  23. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Mar 28, 2024
Nov 3, 20229 citationsCycle 3worst G · actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 13, 2022
  2. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 13, 2022
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 13, 2022
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 13, 2022
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jan 31, 2023
  6. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Dec 13, 2022
  7. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareE · patternCorrected Dec 13, 2022
  8. F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Jan 31, 2023
  9. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Dec 13, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined2.95hrsAbove only 7% of peers−0.78 vs CO avg
  • Registered nursesRN hours only0.76hrsAbove only 48% of peers−0.07 vs CO avg
  • Licensed practical nursesLPN hours0.50hrs
  • Nurse aidesCNA hours1.70hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.68hrs
  • Colorado average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better74%Above only 3% of peersCO avg 49%
  • RN turnoverRegistered nurses only62%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy60 certified beds · ~47 residents a day78%Above only 38% of peersCO avg 79%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $39,316In fines
  • 2Fines
  • 0Payment denials
  • $25,587CO avg in fines
Above only 22% of peersFewer fines than 22% of rated homes in Colorado

Actions on record

  1. Aug 7, 2025Civil money penalty$19,135
  2. Mar 1, 2024Civil money penalty$20,181

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Madison Creek Partners12 facilities in the chain3.3★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Madison Creek Partners LLC
Indirect owners (5%+)
  • Leland Bruce
  • Covey Christensen
Operational or managerial control
  • Leland Bruce
  • Covey Christensen
Corporate directors
  • Rachel Silver
Corporate officers
  • Leland Bruce
  • Covey Christensen
Managing employees
  • Leland Bruce
  • Covey Christensen
  • Rachel Silver

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 065251 · 1625 MEADOWBROOK BLVD, PAONIA, CO, 81428.
  • Percentiles compare this facility with every rated nursing home in Colorado and Delta County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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