Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
PAONIA CARE AND REHABILITATION CENTER
PAONIA, CO · 60 certified beds · Last Life Safety survey August 7, 2025
CMS Certification Number 065251 · first certified March 1989
Ownership
Operated by MADISON CREEK PARTNERS · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
23 citations — more than 68% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was August 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 3, 2022 | 5 |
| March 1, 2024 | 5 |
| August 7, 2025 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 3 | 2025-08-07 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-08-07 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-08-07 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-08-07 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 1 | 2025-08-07 |
| K-0331 | Construct fire resistant interior walls. | 1 | 2025-08-07 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2025-08-07 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2024-03-01 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 7, 2025 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (September 2, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 9, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 1, 2025) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has plan of correction (January 1, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has plan of correction (January 1, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has plan of correction (October 9, 2025) |
March 1, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (March 28, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 4, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 4, 2024) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Waiver has been granted (March 30, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (March 30, 2024) |
November 3, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Waiver has been granted (December 9, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (December 9, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.