Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canon Lodge Care Center during CMS and state inspections, most recent first.
Infection Control and EBP Failures: Housekeeping staff cleaned resident rooms without changing gloves or performing hand hygiene between contaminated and clean tasks, including handling dirty cloths, toilet-cleaning supplies, and mop heads. Staff also failed to follow EBP for residents with catheters: two staff entered a resident’s room for transfer without PPE, and a CNA provided Foley catheter care to another resident on EBP without wearing a gown. The DON, IP, and other staff acknowledged PPE should be used for these care activities.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Failure to Document Consent for Psychotropic Medication Changes: A resident with severe cognitive impairment and multiple psychiatric diagnoses had psychotropic doses increased and one dose decreased, but the record did not show timely notification or documented consent from the responsible party. The MAR showed the new doses were given before the POA was documented as informed at a later care conference, and the DON stated the verbal notification was not documented and no consent form was signed.
A resident with Parkinson's disease, COPD, dysphagia, and HTN was sent to the hospital after a fall with head injury, but the facility did not document that the resident or representative received the required bed hold policy at the time of transfer. Although a signed form was later produced, the date on it matched the resident’s original admission rather than the hospital transfer, and staff confirmed the sending nurse was responsible for providing the notice.
A resident with quadriplegia, cognitive impairment, and total ADL dependence was supposed to be transferred by two staff using a Hoyer lift only. During observation, staff moved the resident for showering and back to his room without the Hoyer lift being used, despite multiple staff members stating the lift was required for every transfer.
Failure to Provide Restorative ROM and Hand Support: Two residents with significant mobility limitations did not receive consistent restorative nursing services to maintain ROM and function. One resident with central cord syndrome and Parkinson's disease had no documented restorative services for several months despite care plan interventions for AROM and PROM, and staff said restorative care had been inconsistent because there was no restorative aide. Another resident with quadriplegia and a contracted left hand was observed multiple times without a splint, palm guard, or rolled washcloth in place, and staff did not provide ROM or the hand support despite the care plan and restorative evaluation calling for it.
A nurse administered Glargine insulin to a resident without priming the insulin pen first. The nurse stated the pen and needle did not require priming, while the DON said insulin pens were to be primed with one unit before use. The resident had an order for Glargine 26 units subcutaneously twice daily for diabetes.
The facility failed to ensure effective discharge planning for three residents, resulting in inadequate documentation and lack of interdisciplinary team involvement. One resident was discharged without a documented plan or established home health services, another had no active discharge planning despite a goal to return home, and a third was discharged without clear plans for home health services or community resources.
The facility failed to provide necessary meal assistance to four residents with cognitive impairments, resulting in inadequate food intake. Despite care plans indicating the need for cueing and supervision, staff did not consistently offer these supports, leading to deficiencies in care.
The facility failed to provide complete discharge summaries for two residents, one with hip osteoarthritis and another with a deep tissue injury and diabetes. Missing information included physical and mental functional status, special treatments, resident needs and goals, and rehabilitation follow-up. The social service director and regional nurse consultant confirmed the deficiencies, and the DON acknowledged the discharging nurse's responsibility for ensuring completion.
A resident with a complex medical history, including low back pain and phantom limb syndrome, experienced inadequate pain management at the facility. Despite reporting pain levels consistently above his acceptable threshold, the facility failed to reassess his pain upon readmission and did not update his care plan to address new pain from a surgical incision. Staff interviews confirmed difficulties in managing the resident's pain, highlighting deficiencies in the facility's adherence to its pain management policy.
The facility failed to provide necessary mental health counseling services to two residents with mental health conditions. One resident, diagnosed with depression and anxiety, was not documented as having received or refused services despite a physician's order. Another resident, with major depressive disorder and schizophrenia, requested telehealth services but lacked documentation of sessions or refusals. Staff interviews revealed inadequate follow-up and documentation by the SSD, leading to the deficiency.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infectious disease. During observation of housekeeping activities, the housekeeping director cleaned a single-occupancy room and then a room occupied by three residents without changing gloves or performing hand hygiene between contaminated and clean tasks. She handled dirty cloths, toilet-cleaning supplies, and mop heads, and she mopped the room and bathroom without changing gloves or performing hand hygiene after touching contaminated items and before touching clean items. In the multi-resident room, she used one mop head for the room and a second mop head for the bathroom, but did not change gloves or perform hand hygiene after handling dirty cloths and before touching the mop heads. The facility also failed to follow enhanced barrier precautions for residents who required them. Resident #2 had a sign on the door indicating EBP and had a catheter, but two unidentified staff members entered the room with a Hoyer lift without donning PPE. Resident #2 stated that when staff transferred him from his wheelchair to his bed, they did not put on gloves or a gown. The infection preventionist and DON stated that staff should wear PPE when transferring a resident on EBP and that PPE should be used for residents with catheters. Additional observation showed CNA #1 providing Foley catheter care to Resident #4, who was on EBP, while wearing gloves but not a gown. CNA #1 then opened the curtain and exited the room after removing gloves and performing hand hygiene. CNA #1 stated staff should wear PPE when performing catheter care, and RN #1 and the DON stated staff were to apply PPE when providing care to a resident with a catheter or open area and that Resident #4 was on EBP.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Document Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to ensure consent was obtained for psychotropic medication changes for one resident with severe cognitive impairment. Resident #26 had diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depression, and cognitive communication deficit, and the April 2025 MDS showed a BIMS score of 3 out of 15. The resident had consent forms on file for Seroquel 50 mg, Escitalopram Oxalate, and Haloperidol 1 mg, but the August 2025 physician orders showed the Seroquel dose was increased to 25 mg three times daily, Escitalopram Oxalate was increased to 10 mg daily, and Haldol was decreased to 0.5 mg twice daily. The July 2025 MAR showed the resident received the increased Seroquel starting on 7/8/25, the increased Lexapro starting on 7/9/25, and the decreased Haldol starting on 7/10/25. The record did not show that the resident's responsible party was notified of these psychotropic medication changes until 7/23/25 during a care conference, 15 days after the Seroquel increase and 14 days after the Lexapro increase. An LPN stated nurses were responsible for notifying the resident and/or family of medication changes and documenting the call, while the DON stated she verbally notified the POA of the psychotropic increase but did not document it in the medical record and did not have the POA sign a consent form.
Failure to Provide Bed Hold Policy at Hospital Transfer
Penalty
Summary
The facility failed to assess, arrange, and document discharge services for one resident reviewed for discharges, specifically by not providing a bed hold policy at the time of transfer to the hospital. Resident #32, who had diagnoses including Parkinson's disease, COPD, dysphagia, and hypertension, was cognitively intact with a BIMS score of 13 out of 15 and required staff assistance with dressing, personal hygiene, transfers, eating, and toileting. The resident had a discharge care plan indicating a desire to remain in the facility for long-term care due to 24-hour care needs. On 5/30/25, staff heard a loud thud and scream, found the resident on the floor outside the nurses' station with his wheelchair behind him, and observed a golf ball-sized red area with bleeding above his right eye; an RN called an ambulance and the resident was sent to the hospital. Record review found no documentation in the EMR showing that the resident or his representative was provided a bed hold policy at the time of transfer. Although the NHA later provided a signed bed hold policy, it was dated 7/28/23, which matched the resident's initial admission date and did not match the hospital transfer date. Staff interviews confirmed the nurse sending the resident out was responsible for providing the bed hold policy, and the DON acknowledged the dates did not match.
Unsafe Transfer of Fully Dependent Resident Without Required Hoyer Lift
Penalty
Summary
The facility failed to ensure a safe transfer was performed for a resident who was fully dependent on staff for all ADLs. The resident had quadriplegia, a history of traumatic brain injury, and an injury of the cervical spinal cord. The MDS indicated the resident was unable to complete the brief interview for mental status, had short-term and long-term memory deficits, was severely impaired in daily decision-making, and required total staff assistance for all ADLs. The resident’s care plan and admission assessment documented that he was totally dependent on two staff for transfers using a Hoyer lift only. During a continuous observation, CNA #2 entered the room with a shower chair, and another CNA entered without a Hoyer lift. The resident was assisted into the shower room and later returned to his room in the shower chair, and the Hoyer lift was not observed in the room during the transfer process. The observation showed the resident was transferred without using the Hoyer lift as recommended. Interviews confirmed that staff understood the resident required a Hoyer lift for transfers. CNA #1, RN #1, the PTA, the DOR, and the DON all stated the resident should be transferred with the Hoyer lift every time. CNA #2 later stated staff performed a three-person transfer without the Hoyer lift because the resident had grabbed the lift earlier, and then said there had been miscommunication and staff thought therapy had already reevaluated him. The DOR stated a two-person transfer was not recommended for a person who could not bear weight and that he would not recommend that method for this resident.
Failure to Provide Restorative ROM and Hand Support
Penalty
Summary
The facility failed to ensure that residents with limited ROM received appropriate restorative nursing services to maintain or improve mobility and prevent further decline. The deficiency involved two residents, both under age 65, who had significant neurologic and mobility impairments and were identified in care plans and restorative evaluations as needing ongoing restorative programming. The report states that the facility did not ensure these residents were offered and provided restorative services as planned, and for one resident, did not ensure a splint, palm guard, or rolled washcloth was placed in the left hand to address a hand contracture. Resident #2 was admitted with central cord syndrome and Parkinson's disease and was cognitively intact. His care plan included gentle ROM, a restorative AROM program for the upper extremities, and PROM for the lower extremities. Although restorative evaluations documented that he had been receiving AROM and PROM earlier in the year, the record contained no restorative evaluations for April, May, June, or August 2025, and no progress notes or other documentation showing he received restorative services during those months. His August 2025 physician orders did not include restorative program services. During interviews, staff stated there had been no consistent restorative aide in the facility for weeks, that restorative services had not been consistent for residents for the last couple of months, and that Resident #2 was not currently receiving restorative services. Resident #14 was admitted with quadriplegia, a history of traumatic brain injury, and cervical spinal cord injury. His MDS showed he was fully dependent for all ADLs and had ROM on both upper and lower extremities. His care plan and restorative evaluation documented a PROM program and a splint or brace program for his contracted left hand, including placing a rolled washcloth in the hand. However, observations showed his left hand remained contracted with the fingertips touching the palm, and at multiple times over two days he did not have a splint, palm guard, or rolled washcloth in place. Staff were observed entering the room and administering medications or assisting the roommate without providing ROM or applying the hand support. The record also lacked documentation that he received PROM restorative services from the time the program was implemented through the observation period. Staff interviews confirmed the restorative program was inconsistent or paused because of staffing, and several staff stated Resident #14 was not receiving restorative programming.
Insulin Pen Not Primed Before Administration
Penalty
Summary
A significant medication error occurred for Resident #10 when RN #2 administered Glargine insulin without priming the insulin pen first. The resident had a physician order for Glargine insulin 26 units subcutaneously twice daily for diabetes. During the observed medication pass, RN #2 prepared the insulin pen by cleansing the top with an alcohol swab, attaching a new needle, and dialing the pen to 26 units at the medication cart. She then brought the prepared medications into the resident’s room, where the resident took oral medication with water before RN #2 prepared the injection site and proceeded with the insulin injection. When asked whether the insulin pen needed to be primed, RN #2 stated that the type of pen and needle used did not require priming. The DON later stated that nurses were to cleanse the top of an insulin pen and prime the needle with one unit, and that failure to prime could cause the wrong dose of insulin to be administered. The report also cited the facility’s insulin pen administration policy, which required insulin pens to be primed for each use in accordance with manufacturer guidance.
Deficient Discharge Planning for Three Residents
Penalty
Summary
The facility failed to ensure an effective discharge planning process for three residents, resulting in deficiencies in documentation and interdisciplinary team involvement. Resident #8, a 76-year-old with moderate cognitive impairment and multiple health conditions, was discharged home without a documented discharge plan in the medical record. The resident's baseline care plan indicated a desire to return home, but the discharge care plan suggested long-term care at the facility. There was no evidence of interdisciplinary team discussions or established home health services upon discharge. Resident #6, a 77-year-old with cognitive intactness and several health issues, had a documented goal to return to the community. However, the medical record lacked documentation of the discharge plan and interdisciplinary team involvement. The resident and family were uncertain about selecting a home health services agency, and there was no evidence of active discharge planning. Resident #7, an 80-year-old with bilateral hip osteoarthritis and replacements, was discharged home without a clear discharge plan. The care plan indicated a desire to return home, but there was no documentation of established home health services or community resources. The discharge summary failed to address the need for rehabilitation services, and there was no evidence of interdisciplinary team involvement in the discharge planning process.
Failure to Provide Meal Assistance to Residents
Penalty
Summary
The facility failed to provide adequate meal assistance to four residents, leading to deficiencies in their care. Resident #13, a 77-year-old with moderate cognitive impairments and a history of dementia, was observed during multiple meals where she did not receive necessary cueing or encouragement to eat. Despite her care plan indicating the need for set-up assistance and cueing, staff failed to provide these interventions, resulting in the resident consuming only partial meals. Resident #5, an 88-year-old with severe cognitive impairment and dysphagia, also did not receive the required hands-on assistance and supervision during meals. Observations showed that the resident was left to eat without cueing or encouragement, leading to minimal food intake. The care plan for Resident #5 specified the need for supervision and set-up assistance, which was not consistently provided by the staff. Similarly, Resident #9 and Resident #14, both with severe cognitive impairments, were not given the necessary supervision and assistance during meals. Resident #9, who required supervision and touching assistance, was left without encouragement, resulting in inadequate food consumption. Resident #14, who needed set-up and feeding assistance, was not provided with the necessary support, leading to her not eating her meal. These failures to adhere to the care plans and provide appropriate meal assistance highlight significant deficiencies in the facility's care practices.
Incomplete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to ensure that discharge summaries were complete for two residents, leading to deficiencies in the discharge process. For the first resident, an 80-year-old with bilateral hip osteoarthritis and total hip replacement, the discharge summary was missing critical information such as physical and mental functional status, continence, communication, special treatments, resident needs and goals, customary routine, pertinent lab results, and rehabilitation follow-up. Additionally, the summary lacked a recapitulation of the resident's stay, including social services and activities, and did not specify whether outpatient rehabilitation services were required. The social service director and regional nurse consultant confirmed that the discharge summaries were incomplete, and the director of nursing acknowledged that the discharging nurse was responsible for ensuring the form's completion. For the second resident, a 76-year-old with a deep tissue injury and diabetes, the discharge summary also lacked essential details, including physical and mental functional status, skin condition, special treatments, resident needs and goals, customary routine, pertinent lab results, and rehabilitation follow-up. The summary did not include a recapitulation of the resident's stay, particularly regarding social services and activities. The social service director admitted to being unable to locate any care conference notes documenting discharge planning for this resident, indicating a lapse in the discharge process. Both cases highlight the facility's failure to provide comprehensive discharge documentation, as required.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to manage pain for a resident in a manner consistent with professional standards of practice. The resident, who was cognitively intact and able to self-propel in a wheelchair, had a history of low back pain, polyneuropathy, peripheral vascular disease, and phantom limb syndrome, among other conditions. Despite these complex medical issues, the facility did not adequately address the resident's pain management needs, as evidenced by the resident's consistent reports of pain levels above his stated acceptable level of 5 out of 10. The facility's pain management policy required comprehensive assessments and individualized care plans, but these were not effectively implemented for the resident. The resident's pain was not reassessed upon readmission, and the care plan failed to address new pain related to a recent surgical incision. The resident frequently reported pain levels of 8 to 10 out of 10, which affected his daily activities and sleep, yet the facility's interventions, including both pharmacological and non-pharmacological measures, were insufficient to bring his pain to an acceptable level. Staff interviews revealed that the resident's pain had been difficult to manage despite changes to his medication regimen. The facility's director of nursing acknowledged that pain assessments should have been conducted more frequently and that the resident's care plan should have been updated to reflect his current pain management needs. The lack of timely and effective interventions, as well as the failure to document and address the resident's pain adequately, contributed to the deficiency in pain management for this resident.
Failure to Provide Mental Health Counseling Services
Penalty
Summary
The facility failed to provide appropriate mental health counseling services to two residents who required such services due to their mental health conditions. Resident #2, who was diagnosed with opioid dependence, chronic pain syndrome, osteoarthritis, depression, and anxiety, was observed crying and reported feeling depressed since admission. Despite a physician's order for a referral for mental health services, there was no documentation in the resident's electronic medical record (EMR) indicating that mental health services were offered or refused. Resident #4, diagnosed with major depressive disorder, paranoid schizophrenia, and other conditions, expressed difficulty managing depression due to personal circumstances and requested telehealth counseling services. Although a psychosocial progress note indicated the resident agreed to telehealth services, there was no documentation of counseling sessions or refusals in the EMR. The facility had recently changed mental health service providers, and the new agency had not yet begun providing services to the resident. Interviews with staff revealed that the Social Services Director (SSD) was responsible for arranging counseling services but failed to document offers or refusals of services. The Director of Nursing (DON) confirmed that a physician's order for counseling services was in place, but the SSD had not followed up adequately. The lack of documentation and follow-up led to the deficiency in providing necessary mental health services to the residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canon City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Care Center | 0 mi | ★★★★★ | 1 | 0 |
| Skyline Ridge Nursing & Rehabilitation Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Hildebrand Care Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Progressive Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Bruce Mccandless Co State Veterans Nursing Home | 8.9 mi | ★★★★★ | 5 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.