Paonia, CO

Paonia Care And Rehabilitation Center

2-star overall rating with 1-star inspections with abuse icon flag with $32,619 in total fines with 12 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle

1625 Meadowbrook Blvd, Paonia, CO

(970) 527-4837

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

47

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Madison Creek Partners

Operator or chain grouping

Approved since

1989-03-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

12 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.76

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.50

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

1.70

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

2.95

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.26

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.68

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.96

CMS adjusted RN staffing hours

Adjusted total hours

3.72

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

62%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

74%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,463

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.59

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.53

Performance 53.33% · Measure score 2.53 · Achievement 2.53 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

2.19

Baseline 3.17 hours · Performance 3.7 hours · Measure score 2.19 · Achievement 2.19 · Improvement 1.54

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission Not Available
10.72%
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community Not Available
50.57%
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary Not Available
1.02
Too few residents or stays to report publicly.
Drug regimen review with follow-up Not Available
95.27%
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Falls with major injury Not Available
0.77%
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened Not Available
2.29%
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 7.27%
8.2%
0.9 pts worse
Numerator 4 · Denominator 55
Staff flu vaccination coverage Not Available
42%
Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.6
1.3
0.7 pts better
1.9
1.3 pts better
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.4
1.7
0.7 pts worse
1.8
0.6 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.7 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 92.9%
93.5%
0.6 pts worse
93.4%
0.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 83.3% · Q3 100.0% · Q4 100.0% · 4Q avg 92.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97.3%
94.7%
2.6 pts better
95.5%
1.8 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3%
Percentage of long-stay residents experiencing one or more falls with major injury 3.2%
3.4%
0.2 pts better
3.3%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.8% · Q3 2.5% · Q4 5.3% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 2.1%
7.4%
5.3 pts better
11.4%
9.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 2.1%
Percentage of long-stay residents who lose too much weight 2.7%
5.0%
2.3 pts better
5.4%
2.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 7.7% · Q4 0.0% · 4Q avg 2.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 20.3%
11.2%
9.1 pts worse
19.6%
0.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 20.6% · Q3 23.1% · Q4 16.2% · 4Q avg 20.3%
Percentage of long-stay residents who received an antipsychotic medication 28.4%
20.6%
7.8 pts worse
16.7%
11.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 28.6% · Q3 31.0% · Q4 24.0% · 4Q avg 28.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 16.4%
15.2%
1.2 pts worse
16.3%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 11.8%
14.6%
2.8 pts better
14.9%
3.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 9.1% · Q3 10.5% · Q4 8.3% · 4Q avg 11.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.8%
0.8 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.7%
1.5%
0.8 pts better
1.7%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 13.5%
22.4%
8.9 pts better
19.8%
6.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 16.1% · Q3 20.4% · Q4 2.4% · 4Q avg 13.5%
Percentage of long-stay residents with pressure ulcers 0.9%
3.7%
2.8 pts better
5.1%
4.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 82.4%
76.4%
6 pts better
81.7%
0.7 pts better
Short Stay · 2024Q4-2025Q3 · Q4 100.0% · 4Q avg 82.4%
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.5%
1.5 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-07 · Fire 2025-08-07

12 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2024-03-01 · Fire 2024-03-01

23 health deficiencies

Top issue: Nutrition and Dietary (6 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2022-11-03 · Fire 2022-11-03

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-07

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-09-02

F · Potential for more than minimal harm 2025-08-07

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-10-09

F · Potential for more than minimal harm 2025-08-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-10-09

F · Potential for more than minimal harm 2025-08-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-09

F · Potential for more than minimal harm 2025-08-07

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-10-09

F · Potential for more than minimal harm 2025-08-07

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-11-01

F · Potential for more than minimal harm 2025-08-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2026-01-01

E · Potential for more than minimal harm 2025-08-07

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-10-09

E · Potential for more than minimal harm 2025-08-07

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-08-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-08-07

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-08-07

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2026-01-01

D · Potential for more than minimal harm 2025-08-07

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2025-10-09

F · Potential for more than minimal harm 2024-03-01

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2024-03-28

F · Potential for more than minimal harm 2024-03-01

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-04

F · Potential for more than minimal harm 2024-03-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-04

F · Potential for more than minimal harm 2024-03-01

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2024-03-30

F · Potential for more than minimal harm 2024-03-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-03-30

F · Potential for more than minimal harm 2022-11-03

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2022-12-09

F · Potential for more than minimal harm 2022-11-03

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2022-12-09

F · Potential for more than minimal harm 2022-11-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-12-09

E · Potential for more than minimal harm 2022-11-03

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2022-12-09

E · Potential for more than minimal harm 2022-11-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-12-09

Inspection history

Recent health citations

G · Actual harm 2025-08-07

F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected 2025-09-02

E · Potential for more than minimal harm 2025-08-07

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-08-07

F887 · Infection Control Deficiencies

Health

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.

Corrected 2025-09-02

D · Potential for more than minimal harm 2025-03-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-04-29

K · Immediate jeopardy 2024-03-01

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-03-01

G · Actual harm 2024-03-01

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-03-28

F · Potential for more than minimal harm 2024-03-01

F801 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-03-28

F · Potential for more than minimal harm 2024-03-01

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-03-28

F · Potential for more than minimal harm 2024-03-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-03-28

F · Potential for more than minimal harm 2024-03-01

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-03-30

E · Potential for more than minimal harm 2024-03-01

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F569 · Resident Rights Deficiencies

Health

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-03-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-28

D · Potential for more than minimal harm 2024-03-01

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-03-28

D · Potential for more than minimal harm 2024-03-01

F626 · Resident Rights Deficiencies

Health

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Corrected 2024-03-28

D · Potential for more than minimal harm 2024-03-01

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-03-28

D · Potential for more than minimal harm 2024-03-01

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2024-03-28

D · Potential for more than minimal harm 2024-03-01

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2024-03-28

D · Potential for more than minimal harm 2024-03-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-03-28

D · Potential for more than minimal harm 2024-03-01

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-03-28

C · Minimal harm 2024-03-01

F574 · Resident Rights Deficiencies

Health

The resident has the right to receive notices in a format and a language he or she understands.

Corrected 2024-03-28

G · Actual harm 2022-11-03

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-01-31

G · Actual harm 2022-11-03

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-12-13

F · Potential for more than minimal harm 2022-11-03

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2022-12-13

E · Potential for more than minimal harm 2022-11-03

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2022-12-13

E · Potential for more than minimal harm 2022-11-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-12-13

E · Potential for more than minimal harm 2022-11-03

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2022-12-13

D · Potential for more than minimal harm 2022-11-03

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2022-12-13

D · Potential for more than minimal harm 2022-11-03

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-12-13

D · Potential for more than minimal harm 2022-11-03

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2023-01-31

Penalties and ownership

What sits behind the stars

$12,438 2025-08-07

Fine

Fine · fine $12,438

Fine

$20,181 2024-03-01

Fine

Fine · fine $20,181

Fine

Ownership

Madison Creek Partners LLC

5% Or Greater Direct Ownership Interest · Organization

100% 10 facilities 2016-07-01
Christensen, Covey

5% Or Greater Indirect Ownership Interest · Individual

70% 12 facilities 2016-07-01
Bruce, Leland

5% Or Greater Indirect Ownership Interest · Individual

30% 1 facilities 2016-07-01
Bruce, Leland

Operational/Managerial Control · Individual

0% 1 facilities 2016-07-01
Bruce, Leland

Corporate Officer · Individual

0% 1 facilities 2016-07-01
Bruce, Leland

W-2 Managing Employee · Individual

0% 1 facilities 2016-07-01
Christensen, Covey

Operational/Managerial Control · Individual

0% 12 facilities 2016-07-01
Christensen, Covey

Corporate Officer · Individual

0% 12 facilities 2016-07-01
Christensen, Covey

W-2 Managing Employee · Individual

0% 12 facilities 2016-07-01
Silver, Rachel

Corporate Director · Individual

0% 1 facilities 2016-07-01
Silver, Rachel

W-2 Managing Employee · Individual

0% 1 facilities 2016-07-01

Nearby options

Other facilities in reach

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Horizons Care Center

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3-star overall rating with 3-star inspections with $34,174 in total fines with 11 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

Overall
3 / 5
Health
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Staffing
4 / 5
Fines
$34,174
#2

Willow Tree Care Center

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1-star overall rating with 1-star inspections with abuse icon flag with 13 recent health deficiencies

Overall
1 / 5
Health
1 / 5
Staffing
3 / 5
Fines
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#3

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2-star overall rating with 2-star inspections with abuse icon flag with $10,059 in total fines with 11 recent health deficiencies

Overall
2 / 5
Health
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