Safety Report: Paonia Care and Rehabilitation Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
1Immediate jeopardy citations (severity J–L)
5Actual harm citations (severity G–I)
6Requirements cited on more than one inspection
G
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
G
Government finding: 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 F603
K
Government finding: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies · Tag F805
G
Government finding: Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Tag F692
G
Government finding: Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Tag F692
G
Government finding: 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 F689
Citations by topic
8Abuse, neglect & exploitation
5Infection control
3Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (13) than in the cycle before (24).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 3 | August 7, 2025; March 24, 2025; November 3, 2022 |
| Ensure that residents are free from significant medication errors. (F760) | 2 | July 14, 2026; March 1, 2024 |
| Provide and implement an infection prevention and control program. (F880) | 2 | August 7, 2025; March 1, 2024 |
| Provide enough food/fluids to maintain a resident's health. (F692) | 2 | March 1, 2024; November 3, 2022 |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (F867) | 2 | March 1, 2024; November 3, 2022 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | March 1, 2024; November 3, 2022 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| August 7, 2025 | Fine | $12,438 |
| March 1, 2024 | Fine | $20,181 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
July 14, 2026 — 2 citations (includes serious) · complaint investigation
G
Ensure that residents are free from significant medication errors.
Actual harm to a resident (not immediate jeopardy) · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected April 30, 2026
D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F628 · complaint · corrected August 10, 2026
August 7, 2025 — 11 citations (includes serious)
G
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F603 · corrected September 2, 2025
E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected September 2, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F887 · corrected September 2, 2025
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F883 · corrected September 2, 2025
D
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F881 · corrected September 2, 2025
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected September 2, 2025
D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · corrected September 2, 2025
D
Provide care or services that was trauma informed and/or culturally competent.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F699 · corrected September 2, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected September 2, 2025
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected September 2, 2025
D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F605 · corrected September 2, 2025
March 24, 2025 — 1 citation · complaint investigation
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected April 29, 2025
March 1, 2024 — 23 citations (includes serious)
K
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Immediate jeopardy to resident health or safety · Pattern · Nutrition and Dietary Deficiencies · F805 · corrected March 1, 2024
G
Provide enough food/fluids to maintain a resident's health.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F692 · complaint · corrected March 28, 2024
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected March 30, 2024
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected March 28, 2024
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F803 · corrected March 28, 2024
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F801 · corrected March 28, 2024
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected March 28, 2024
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · complaint · corrected March 28, 2024
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected March 28, 2024
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 28, 2024
E
Ensure the activities program is directed by a qualified professional.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F680 · corrected March 28, 2024
E
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · complaint · corrected March 28, 2024
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected March 28, 2024
E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F569 · corrected March 28, 2024
E
Honor the resident's right to manage his or her financial affairs.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F567 · corrected March 28, 2024
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · corrected March 28, 2024
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected March 28, 2024
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · corrected March 28, 2024
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · corrected March 28, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected March 28, 2024
D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F626 · corrected March 28, 2024
D
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F552 · corrected March 28, 2024
C
The resident has the right to receive notices in a format and a language he or she understands.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F574 · corrected March 28, 2024
November 3, 2022 — 9 citations (includes serious)
G
Provide enough food/fluids to maintain a resident's health.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F692 · corrected December 13, 2022
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · corrected January 31, 2023
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected December 13, 2022
E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F744 · corrected December 13, 2022
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · corrected December 13, 2022
E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected December 13, 2022
D
Provide or get specialized rehabilitative services as required for a resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F825 · corrected January 31, 2023
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · corrected December 13, 2022
D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected December 13, 2022
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare