Above average — CMS composite of the measures below.
The next survey window likely opens 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 Hildebrand Care Center during CMS and state inspections, most recent first.
Improper medication storage and labeling were found on multiple med carts. Surveyors observed loose pills in a drawer, a saline gel and an insulin pen without resident labels, several inhalers and insulin products without dates opened, and expired epinephrine and insulin still stored on the carts. The DON and pharmacist confirmed the items should have been labeled or discarded according to manufacturer guidance.
PRN lorazepam was ordered for a resident with dementia, anxiety, and depression without a 14-day limit and without documented physician rationale for continued use beyond that timeframe. The resident remained on the PRN antianxiety medication, and the MAR showed a dose was administered, but the record contained no note showing the order was reevaluated or justified as required; the DON was unaware of the 14-day rule, and the pharmacist confirmed no rationale was documented.
Improper resident transfers: Staff failed to follow ordered transfer assistance for two residents. One resident with stroke-related weakness and moderate cognitive impairment was transferred alone without the required two-person assistance and gait belt, and she later reported knee pain. Another resident with dementia and severe cognitive impairment was also transferred by one CNA with a gait belt even though two-person assistance was ordered; a second staff member was present but did not assist.
A resident with dysphagia and dementia was served an incorrect diet texture, leading to a choking incident in the dining room. The resident was hospitalized with acute hypoxic respiratory failure and later diagnosed with severe acute hypoxic encephalopathy. Despite medical efforts, the resident's condition did not improve, and she passed away after being readmitted to the facility under hospice care.
Improper Medication Storage and Labeling
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional principles because multiple medication carts contained improperly stored drugs and biologicals. Surveyors found loose pills in the bottom of one cart drawer, and staff stated the drawer should have been cleaned and should not have contained that many loose pills. The facility also had medications that were missing required resident identification labels, including a saline nasal gel and an insulin lispro pen. Several inhalers and insulin products were found without the dates they were opened, despite manufacturer instructions requiring dating after opening. These included Wixela, Incruse Ellipta, Umeclidinium/Vilanterol Ellipta, and Trelegy Ellipta inhalers for multiple residents, as well as an insulin glargine pen and an insulin lispro vial. Staff acknowledged that inhalers and insulin should have been labeled with the date opened, and the pharmacist stated that dry inhalers should have been labeled with the date they were opened. Surveyors also found expired medication in storage. An epinephrine auto-injector labeled for one resident had an expiration date that had passed, and an insulin lispro vial for another resident had been opened beyond the 28-day use period. The DON confirmed that the epinephrine should have been discarded and that the insulin pen should have been discarded 28 days after opening.
PRN Lorazepam Not Reevaluated Beyond 14-Day Limit
Penalty
Summary
The facility failed to adequately monitor Resident #7 for unnecessary psychotropic medication use when the physician's PRN lorazepam order was not reevaluated after the 14-day limit and no physician rationale was documented to justify continued use beyond that period. Resident #7 was over 80 years old, admitted with diagnoses including dementia, anxiety, and depression, and the September 2025 MDS indicated the resident was cognitively intact with a BIMS score of 14 out of 15 and was receiving antianxiety medications. Review of the September 2025 physician orders showed lorazepam 0.5 mg by mouth every two hours as needed for anxiety or shortness of breath, ordered indefinitely on 8/18/25 rather than for 14 days. The resident's psychotropic medication care plan addressed depression, anxiety, hallucinations, and insomnia, and the MAR showed a PRN lorazepam dose was given on 9/13/25 at 8:00 p.m. Progress notes contained no documentation that the physician reevaluated the PRN lorazepam or documented a rationale for continuing it beyond 14 days. The DON stated she was not aware of the 14-day requirement, and the pharmacist confirmed there was no physician rationale documented in the medical record.
Improper resident transfers
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents when two residents were transferred in a manner that did not match their care plans and transfer orders. The deficiency involved Resident #10 and Resident #39, both of whom required specific transfer assistance for safety. The report states that staff did not follow the ordered transfer methods for either resident during separate incidents involving one-person transfers when two-person assistance was required. Resident #10 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, hypertension, and muscle weakness. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 9 and need for substantial assistance with ADLs. Her care plan and physician orders identified her as needing transfer assistance, including use of a gait belt and two-person assistance with a pivot disc, later changed to two-person assistance with a gait belt and transfer pole. The resident reported that a CNA transferred her alone without a gait belt while she was sitting in her lounge chair, causing her to twist and hurt her knee. The record shows she later reported increased left knee pain, and the facility’s investigation documented that on the date of the incident she was transferred with one person using a gait belt even though her transfer status and physician order required two-person assistance. Resident #39 had diagnoses including dementia, muscle weakness, and chronic kidney disease. Her MDS showed severe cognitive impairment with a BIMS score of 6 and dependence or substantial assistance for multiple ADLs, including transfers. Her care plans directed staff to use two-person assistance with a gait belt for transfers and included other mobility-related interventions. The facility’s investigation documented that she was transferred by one CNA using a gait belt even though her transfer status and physician order required two-person assistance. A second staff member was present in the room but did not assist before the transfer occurred. The resident was assessed afterward and no injuries were noted, and the representative was notified that the transfer had been done by one person instead of two.
Resident Chokes Due to Incorrect Diet Texture
Penalty
Summary
The facility failed to provide a resident with the correct physician-ordered mechanical soft texture diet, which was crucial due to the resident's history of dysphagia and dementia. On the day of the incident, the resident was served large pieces of steak, mashed potatoes, and a bread roll, which were not in compliance with the mechanical soft diet order. This oversight led to the resident choking in the dining room, requiring the Heimlich maneuver and emergency services. The choking incident resulted in the resident being admitted to the hospital with acute hypoxic respiratory failure. A large piece of meat was removed from the resident's trachea in the emergency room. Despite medical intervention, the resident's mental status did not recover, and she was diagnosed with severe acute hypoxic encephalopathy. The resident was eventually readmitted to the facility under hospice care and passed away seven days after the choking incident. Interviews and record reviews confirmed that the facility's failure to serve the correct diet texture was a significant factor in the resident's decline. The dietary staff's error in serving the wrong meal, possibly due to a confusing tray card system, was identified as the cause of the incident. The facility acknowledged the deficiency and took corrective actions to address the issue.
Removal Plan
- A huddle was conducted with the dietary staff to discuss the incident of Resident #1's choking.
- An educational in-service was conducted for all dietary staff regarding the importance of ensuring residents received the correct physician-ordered diet texture. The education included a review of all diet textures.
- The facility implemented a new system of diet cards for all residents. The facility implemented one card that included the diet texture, resident preferences, resident allergies, and the resident's food order for each meal.
- Education was provided to all staff, including dietary and nursing staff, on the new system put in place to ensure residents received the correct diet texture.
- An education write-up was completed for a dietary staff member.
- Annual skills testing was conducted for all staff on diet textures, modified liquids and the importance of following physician-ordered diet textures. The facility conducted direct observations of staff serving meals with the correct diet tickets following the skills testing.
- Meal service audits were started and continued daily at different meals. Audits would be continued indefinitely.
- All audits were to be reviewed daily by the dietary manager, discussed weekly in the interdisciplinary team meetings (IDT), and reviewed during monthly QAPI (quality assurance and performance improvement) meetings.
- The new process was added to the skills fair and competency checklist.
- A blue binder was placed in the kitchen with every resident's diet texture, assistance level and any assistive devices.
- All dietary staff and nursing staff had been educated on the binder and had access to the binder. The binder was checked every morning to ensure any diet changes were implemented.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 7 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) |
|---|---|---|---|---|
| Progressive Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Skyline Ridge Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Valley View Care Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Canon Lodge Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Bruce Mccandless Co State Veterans Nursing Home | 8.3 mi | ★★★★★ | 5 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hildebrand Care Center.
100% money-back within 48 hours.
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.