Paonia Care and Rehabilitation Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 9 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (2/5 stars)
- Above-median deficiencies (12 vs median 7)
- High staff turnover (74%)
- High RN turnover (62%)
Below average in CO · Meets national RN staffing standard · Very high staff turnover · Below chain average · $32,619 in fines · Abuse citation
What this means for your family
The facility appears to have made positive strides under recent leadership, particularly regarding resident engagement and family inclusion. However, given past reports of serious communication gaps during medical emergencies, we strongly advise families to maintain a proactive role in monitoring their loved one's health status and to keep a detailed inventory of personal property.
Google Reviews
Google Reviews
9 reviews on Google“Paonia Care and Rehabilitation Center receives polarized feedback, with some families praising the compassionate, personalized care for long-term residents and others raising serious concerns about neglect and administrative oversight. While recent reviewers highlight positive leadership and staff engagement, historical reports of communication failures and property loss suggest a need for families to remain highly involved in their loved one's care.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and caring nursing staff
- Welcoming environment for families
- Strong leadership and service improvements
- Accommodating to family dining and visitation
Concerns
- Allegations of neglect and poor medical oversight (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 9 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1Given the recent focus on service improvements mentioned by your leadership team, what specific changes have been implemented to enhance the quality of medical oversight for residents?
- 2With 12 recent state violations noted, could you walk us through the corrective action plan currently in place to address these health inspection findings?
- 3How do you ensure consistent, high-quality care for residents during shift changes, especially given the current staffing rating?
- 4I’ve read positive feedback about your team being welcoming to families during mealtimes; how do you incorporate family involvement into the daily activities and social life of the residents?
- 5To address concerns regarding medical responsiveness, what is your facility's protocol for communicating changes in a resident's health status to their family members?
- 6Since your team has been praised for being accommodating, what opportunities exist for families to provide direct feedback on their loved one's care plan?
Personalized based on this facility's data
Key Review Excerpts
“We just loved the care that Aunt Opal received at the Paonia Care Home...she was a brilliant teacher for years..and the staff made her feel loved and encouraged her to still use that brilliant mind....she lived to be 105...amazing!”
“My mother was up there over a year. Everyone was so kind and always accommodated us whenever we wanted to dine with her. She was always clean and they were always keeping us informed.”
“My dad had dementia and has been here for almost two years now. The staff is very caring, welcoming, and love dad. He is safe and settled there.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 16 measures
10
measures
2
measures
4
measures
Residents on antipsychotic medication
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Residents with pressure sores (bedsores)
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility shows ongoing problems with nutrition and dietary services, safety and fire code compliance, and infection control across multiple surveys. While all cited deficiencies have been corrected, recurring issues with nutrition services, fire safety systems, and quality oversight suggest systemic challenges. Families have filed complaints resulting in citations for inadequate food service, safety hazards, activities programs, and resident protection, indicating real resident care concerns that warrant careful consideration during visits.
Aug 7, 2025Routine24
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
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.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Construct fire resistant interior walls.
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Mar 24, 2025Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Mar 1, 2024Routine24
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Nutrition and Dietary Deficiencies
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
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
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
Resident Rights Deficiencies
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Resident Rights Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure the activities program is directed by a qualified professional.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Resident Assessment and Care Planning Deficiencies
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
Plan the resident's discharge to meet the resident's goals and needs.
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
Mar 1, 2024Complaint4
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nov 3, 2022Routine14
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Egress Deficiencies
Install proper backup exit lighting.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
Federal Penalties
Fine
Aug 7, 2025
$12,438
Fine
Mar 1, 2024
$20,181
State Inspection History
State Inspections
Source: CO Dept. of Public Health & Environment
May 14, 2025ComplaintCleanReport
No deficiencies found during this inspection.
Mar 24, 2025Complaint
A complaint survey, prompted by #CO36700, Incident #39499 and Incident #39502 was conducted on 3/20/25 to 3/24/25. One deficiency was cited. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.
Jun 17, 2024Follow-upCleanReport
No deficiencies found during this inspection.
Apr 26, 2024Follow-upCleanReport
No deficiencies found during this inspection.
Apr 26, 2024ComplaintCleanReport
No deficiencies found during this inspection.
Apr 15, 2024Routine
Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/08/2024 and 04/14/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.
Apr 8, 2024Routine
Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/01/2024 and 04/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.
Ownership & Operations
Who Operates This Facility
Paonia Care and Rehabilitation Center
for profit
Chain Affiliation
Madison Creek Partners
13 facilities nationwide
Chain avg rating: 3.2/5 · Rank 10 of 12
Ownership & Management
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
9 reviews from families & visitors
Official Website
Visit paoniacare.com
Medicare data downloads
Original nursing home datasets
CO CDPHE — View Official Record
Public-record source of inspection history and licensure data shown on this page
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