Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Skyline Ridge Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment were involved in a physical altercation after one wandered into the other's room and bed, resulting in facial injuries. The incident was witnessed by a CNA who failed to report it, and intended interventions such as room separation and stop signs were not effectively implemented, with staff failing to notice repeated unauthorized room entries.
The facility failed to employ a qualified infection preventionist (IP) with specialized training, affecting all residents. After the previous IP resigned, a staff nurse was assigned without the necessary certification. The Director of Nursing (DON) and corporate resource nurse (CRN) managed the program, but neither had the required certification until the survey, indicating a deficiency in the infection prevention and control program.
The facility failed to maintain an effective infection prevention and control program, particularly in the administration and documentation of COVID-19 vaccinations for several residents. Records and interviews revealed missing documentation of vaccine offers, administration, or declination, with some residents testing positive for COVID-19. Staff admitted to inconsistencies in vaccine documentation, highlighting a significant gap in infection control practices.
A resident experienced severe weight loss due to the facility's failure to provide adequate nutritional care and assistance during meals. Despite being identified as malnourished, the resident's nutritional interventions were not effectively monitored, and assistance was not provided during meals, leading to a significant decline in weight.
A resident with a history of falls and requiring a mechanical lift for transfers fell and sustained a fracture when a CNA attempted a transfer without a second staff member, contrary to protocol. Observations showed ongoing deficiencies, with the resident's call light out of reach and a fall mat not in place, indicating inconsistent implementation of fall prevention measures.
The facility failed to complete discharge summaries for four residents, missing critical information such as functional status, continence, and rehabilitation follow-up. The issue was linked to the use of incorrect forms and was not identified by the facility before the survey.
The facility failed to ensure proper infection control practices, as staff did not assist some residents with hand hygiene before meals, and a laundry aide improperly handled clean laundry by holding it against her uniform. This led to potential contamination risks, as observed in the dining room and during laundry delivery.
The facility failed to maintain accurate records of residents' CPR status, leading to discrepancies between MOST forms, care plans, and the CPR list used by nursing staff. This resulted in incorrect documentation of residents' wishes regarding resuscitation, as staff relied on an outdated CPR list instead of the MOST form book.
Two residents in a memory care unit were involved in a physical altercation, resulting in injuries. The facility failed to prevent the incident despite having care plans in place. In a separate incident, a resident slapped her spouse, and the facility delayed reporting the abuse. Both incidents highlight deficiencies in abuse prevention and timely reporting.
A facility failed to ensure a resident was free from physical restraints by using a bed alarm without a physician's order, safety risk assessment, or attempting alternative interventions. The resident, with Alzheimer's and glaucoma, was dependent on staff for daily activities. Staff interviews revealed the alarm was used for fall prevention, but there was no documentation of a safety risk assessment or alternative treatments in the resident's medical record.
A facility failed to report a resident-to-resident physical abuse incident to authorities within the required 24-hour timeframe. A volunteer witnessed one resident slapping another and reported it to staff the next day. The facility delayed reporting to the State Agency and local police, misunderstanding the reporting window as 48 hours instead of 24.
A resident with dementia and cognitive impairment did not receive necessary cueing and encouragement during meals, leading to inadequate nutritional intake. Despite the care plan indicating the need for supervision and alternatives, staff failed to provide the required assistance, as observed during multiple meal times.
A facility's medication error rate was found to be 7.69%, exceeding the acceptable threshold of 5%. This was due to a registered nurse administering medications 39 minutes past the scheduled time, as the nurse had to re-approach a resident who was having a difficult day. The interim director of nursing and the nursing home administrator were surprised by the late administration.
The facility failed to properly secure medications in the Pine Ridge medication refrigerator, which was repeatedly found unlocked. Staff reported difficulties with the locking mechanisms, and the NHA had not addressed these issues. This resulted in potential unauthorized access to medications, as non-facility employees and residents were nearby.
Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure adequate supervision and intervention to prevent physical abuse between residents. Specifically, a cognitively impaired resident with a history of wandering entered another resident's room and bed, resulting in a physical altercation. The resident whose bed was entered attempted to remove the wandering resident, leading to the latter sustaining a bloody nose and developing a black eye. The incident was witnessed by a certified nurse aide (CNA), but the CNA did not report the event as required by facility policy. The resident who was injured had severe cognitive impairment, required substantial assistance with activities of daily living, and exhibited wandering behaviors. The resident was found the next morning with facial bruising and dried blood, which was only then reported to nursing staff. Medical evaluation confirmed facial contusions. The resident who attempted to remove the wandering resident also had severe cognitive impairment and a history of confusion, wandering, and occasional verbal altercations, but no prior physical aggression. Observations during the survey revealed that interventions intended to prevent recurrence, such as room changes and the use of stop signs to deter entry, were not effectively implemented. The rooms of the two residents remained adjacent, and no stop sign was present on the door as indicated in the facility's investigation. Additionally, staff failed to notice when other residents entered the same room and bed, indicating ongoing lapses in supervision and monitoring. Staff interviews confirmed that reporting protocols and monitoring practices were not consistently followed at the time of the incident.
Deficiency in Infection Preventionist Qualification
Penalty
Summary
The facility failed to employ a qualified infection preventionist (IP) who had completed specialized training in infection prevention and control, which had the potential to affect all residents residing in the facility at the time of the survey. The facility's previous full-time IP resigned, and her last day of working in the facility was on October 25, 2024. Following her resignation, the facility assigned a current staff nurse to the IP position on January 8, 2025, who did not have a certificate documenting the completion of IP education and training. The Director of Nursing (DON) and the corporate resource nurse (CRN) were managing the infection prevention program, but neither had the required certification at the time. The CRN, who was a corporate employee working at the facility, claimed to have completed the IP education modules but was unable to provide a certificate of completion until January 15, 2025, during the survey. This indicates that the facility did not have a qualified IP in the building from October 25, 2024, until January 15, 2025. The CRN worked at least half-time as the facility's IP, orienting and training the DON and the newly appointed IP, in addition to providing support to other corporate facilities. However, the lack of a qualified IP during the specified period constituted a deficiency in the facility's infection prevention and control program.
Inadequate COVID-19 Vaccination Documentation and Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the administration and documentation of COVID-19 vaccinations for seven residents. The deficiency was identified through records review and interviews, revealing that the facility did not ensure the tracking, offering, and administration of the COVID-19 vaccine for these residents. The facility's policy required that all residents be offered vaccines, with documentation of either acceptance or refusal, including education on the benefits and potential side effects. However, the electronic medical records (EMR) for the affected residents lacked evidence of these processes. Interviews with residents indicated a lack of recall regarding being offered the COVID-19 vaccine, and the EMR reviews showed missing documentation of vaccine offers, administration, or declination. For instance, one resident's refusal form was undated, and there was no evidence of education provided. Another resident signed a consent form, but there was no record of vaccine administration. Several residents tested positive for COVID-19, yet their records did not reflect proper vaccine documentation or education. Staff interviews revealed that the infection preventionist had resigned, leaving the Director of Nursing (DON) and the corporate resource nurse (CRN) to manage the infection prevention program. They admitted to inconsistencies in the vaccine roster and EMR documentation, which did not accurately reflect vaccine administration details such as dates, lot numbers, and staff responsible. The CRN confirmed that the handwritten information on the vaccine roster was insufficient to determine if vaccines were administered, highlighting a significant gap in the facility's infection control practices.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to meet their nutritional needs, resulting in severe weight loss. The resident, who was admitted with multiple diagnoses including osteoporosis, hypokalemia, hypocalcemia, hypomagnesemia, cognitive communication deficit, and cerebral infarction, was identified as malnourished shortly after admission. Despite implementing snacks three times a day, the facility did not have a system to monitor the resident's acceptance of these nutritional interventions, leading to a significant weight loss of 15.9 pounds over three months. Observations revealed that the resident had difficulties eating independently due to tremors, which caused food to spill. The resident was not offered assistance during meals, and on several occasions, meals were removed after minimal consumption without offering alternatives. The resident's nutritional care plan indicated a risk for the inability to maintain nutrition, but interventions were not effectively implemented or monitored, contributing to the resident's continued weight decline. Interviews with staff indicated a lack of awareness and communication regarding the resident's need for assistance during meals. The registered dietitian noted the severe weight loss and attempted to implement dietary changes and supplements, but these were not adequately monitored for effectiveness. The facility's failure to provide adequate assistance and monitor nutritional interventions resulted in the resident's severe weight loss and unmet nutritional needs.
Failure to Ensure Safe Transfer and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment for Resident #59, who had a history of falls and required a sit-to-stand mechanical lift for transfers. On the night of 7/31/24, a certified nurse aide (CNA) attempted to transfer the resident without the assistance of a second staff member, contrary to the facility's protocol. This resulted in the resident falling and sustaining a displaced fracture of the distal right radial metaphysis. The CNA and a licensed practical nurse (LPN) assisted the resident back to bed without following proper post-fall procedures, and the resident's representative was not notified immediately. Observations during the survey revealed ongoing deficiencies in the facility's fall prevention measures. Resident #59 was observed in her room with her call light out of reach, and a fall mat, which was supposed to be on the floor next to her bed, was found tucked away in the closet. These observations indicated that the facility staff failed to consistently implement fall interventions for the resident, despite her known risk factors and history of falls. The facility's policies on fall risk assessment and clinical falls management were not adequately followed. The resident's care plan included interventions such as keeping the call light within reach and using a fall mat, but these were not consistently in place. Staff interviews confirmed that the call light and fall mat were not properly positioned, and the CNA involved in the initial fall admitted to not following the required protocol for mechanical lift transfers.
Removal Plan
- A resident was sent to the emergency room for an x-ray due to a change in pain rating, and a swollen wrist and arm.
- An investigation started upon the radiology report findings.
- The nurse who failed to document fall assessment, post fall follow up and notification of family was suspended.
- CNA suspended pending investigation.
- Notified the medical director.
- Facility will review the last 30 days of resident falls to identify any injury that might have occurred and went unreported or unassessed.
- Facility will review the last two weeks of the 24-hour report to identify any change of condition that was not assessed and followed up on.
- Facility will review residents who require mechanical lift transfers and ensure transfer status is on the residents' care plan.
- All nursing staff will be educated by the director of nursing or designee on ensuring two staff are present for all mechanical lift transfers, the facility fall management and investigation policy, to include safe positioning of resident in a bed, documentation required post fall including assessment and notification of resident after a fall.
- An attendance sheet will be reconciled with an active staff roster and nursing staff that were unable to attend will be provided with one-on-one re-education.
- The interdisciplinary team will review any concerns from the prior business day and ensure residents who have experienced any change in condition have been appropriately assessed and any follow up has been documented and reported to family and medical director.
- The director of nursing or designee will conduct record reviews post fall to ensure policy and procedures were followed weekly for four weeks, then monthly for two months, then as needed thereafter.
- Director of nursing or designee will observe three random staff utilizing a mechanical lift weekly for four weeks, then monthly for two months, then as needed thereafter.
- Any non-compliance finding will be dealt with immediately.
- All findings will be tracked and trended and reported to the quality assurance performance improvement committee monthly for three months and then as needed to ensure the plan is implemented, sustained and evaluated for its effectiveness.
Incomplete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that discharge summaries were completed for four residents who were discharged, as identified in a survey. The discharge summaries were missing critical information such as physical and mental functional status, continence, skin condition, vision, special treatments and procedures, dental and nutritional information, activities pursuit, resident needs, strengths and goals, customary routine, pertinent lab test results, and rehabilitation follow-up or potential. This deficiency was noted for residents who were discharged to various settings, including home with home health services and an independent living facility. Resident #236, who was discharged home after joint replacement surgery, had a discharge summary that was incomplete, lacking details on their functional status and rehabilitation follow-up. Similarly, Resident #84, who had multiple diagnoses including sepsis and heart failure, was discharged home with outpatient rehabilitation services, but their discharge summary was still in progress months after discharge. Resident #85, discharged to an independent living facility, also had an incomplete discharge summary, missing similar critical information. Resident #238, discharged home with a diagnosis of mechanical loosening of a knee prosthetic joint, had a discharge summary that was not completed by the end of the survey. Interviews with the interim director of nursing and a corporate consultant revealed that the facility was using the wrong form for discharge summaries, which contributed to the incomplete documentation. The facility had not identified these concerns prior to the survey.
Infection Control Deficiencies in Hand Hygiene and Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of appropriate hand hygiene offered to residents before meals. Observations revealed that while some residents were able to independently use the provided warm green wet cloths to sanitize their hands, others who required assistance did not receive help from staff. For instance, Resident #4 was seen eating with unsanitized hands, and Resident #59, who was assisted to the dining room by a CNA, was not offered hand hygiene before consuming her meal. Additionally, the facility did not handle clean laundry in a sanitary manner. A laundry aide was observed delivering clean clothing to residents' rooms by holding the clothes against her uniform, rather than using the designated cart. This practice was contrary to the facility's policy, which requires clean laundry to be protected from contamination during transport. The laundry aide admitted to not being aware that holding clean clothes against her uniform could lead to contamination. Interviews with the infection preventionist and corporate consultant confirmed the expectations for hand hygiene and proper handling of laundry. The infection preventionist acknowledged the importance of hand hygiene in preventing disease transmission and stated that staff should not transport clean laundry against their bodies to avoid contamination. The corporate consultant indicated that the facility should provide residents with individually wrapped hand-sanitizing wipes before meals.
Inaccurate Documentation of CPR Status
Penalty
Summary
The facility failed to maintain accurate medical records for four residents regarding their cardiopulmonary resuscitation (CPR) status. This deficiency was identified through record reviews and staff interviews, revealing discrepancies between residents' Medical Orders for the Scope of Treatment (MOST) forms, care plans, and the CPR list used by nursing staff. For instance, one resident's MOST form and physician's order indicated a do-not-resuscitate (DNR) status, yet the care plan and CPR list incorrectly documented the resident as a full code, meaning they would receive CPR. Another resident's representative had indicated a desire for CPR on the MOST form, and the care plan reflected this full code status. However, the resident was not listed on the CPR list page in the narcotics book, which was the primary resource used by nurses to determine CPR status during emergencies. Similar discrepancies were found for two other residents, where their documented wishes and physician orders were not accurately reflected in the CPR list used by the nursing staff. Interviews with nursing staff revealed reliance on an outdated CPR list in the narcotics book, which was not the proper resource for checking residents' code status. The interim director of nursing acknowledged this issue and indicated that the MOST form book at the nurses' stations should have been used instead. The deficiency highlights a lack of an effective process to ensure that residents' CPR directives were accurately maintained and accessible to nursing staff during medical emergencies.
Failure to Prevent Resident-to-Resident Altercations and Timely Report Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in deficiencies related to resident safety and abuse prevention. The first incident involved a physical altercation between two residents in the memory care unit. Resident #239, who had severe cognitive impairment and a history of aggressive behavior, hit Resident #38, causing a laceration and bruising. The altercation was unwitnessed by staff, and the facility became aware of the incident only after Resident #38 was found bleeding. Both residents were assessed and sent to the hospital for evaluation. The facility's care plan for Resident #239 included interventions for managing aggressive behavior, but these measures were insufficient to prevent the altercation. In the second incident, Resident #70 slapped her spouse, Resident #74, during an interaction observed by a facility volunteer. The volunteer reported the incident to staff the following day, and it was subsequently reported to state and local authorities two days later. The delay in reporting the incident violated the facility's policy for timely reporting of abuse allegations. The facility's investigation found no prior behavioral issues between the couple, and the family agreed to allow them to continue sharing a room. However, the facility's failure to report the incident promptly and ensure the safety of both residents constituted a deficiency. Both incidents highlight the facility's failure to implement effective measures to prevent resident-to-resident altercations and ensure timely reporting of abuse. The facility's policies and procedures for abuse prevention and reporting were not adequately followed, leading to deficiencies in resident safety and compliance with regulatory requirements. The facility's response to the incidents, including the separation of residents and initiation of investigations, occurred after the deficiencies had already occurred.
Failure to Ensure Resident Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically a bed alarm, without obtaining a physician's order, completing a safety risk assessment, or attempting alternative interventions. The resident in question, an 85-year-old with Alzheimer's disease and glaucoma, was dependent on staff for various activities of daily living. Observations revealed that a bed alarm was attached to the resident's bed, which was activated by a magnet attached to a string clipped to the resident's clothing. This setup was intended to alert staff if the resident moved too far, potentially preventing falls. Interviews with facility staff, including the interim director of nursing and registered nurses, indicated that the bed alarm was used as a fall prevention measure. However, there was no documentation in the resident's electronic medical record of a safety risk assessment or evidence that alternative treatments were attempted before implementing the alarm. The interim director of nursing stated that a physician's order was not required for the alarm, and the interdisciplinary team reviewed the resident's status before attaching the device. Despite these claims, the lack of proper documentation and assessment led to the deficiency finding.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident physical abuse to the State Survey and Certification Agency and local police within the required 24-hour timeframe. The incident involved Resident #70 slapping Resident #74, her spouse, with force while assisting with clothing. This altercation was witnessed by a facility volunteer who separated the residents and reported the incident to facility staff the following day. However, the facility did not report the incident to the appropriate authorities until two days after it was reported by the volunteer. The facility's policy, revised in September 2022, mandates that all reports of resident abuse be communicated to local, state, and federal agencies immediately, within two hours of the allegation. The Nursing Home Administrator (NHA) acknowledged the delay, attributing it to the volunteer's misunderstanding of the reporting window, believing it to be 48 hours instead of the required 24 hours. The NHA also stated that the volunteer was educated on the immediate reporting requirements, but the facility still failed to comply with the mandated reporting timeframe.
Failure to Assist Resident with ADL During Meals
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident with significant cognitive impairment, specifically during meal times. The resident, who was over 65 years old and diagnosed with dementia, mood disturbance, and anxiety, required supervision and cueing while eating. Observations revealed that during multiple meal times, the resident was left without encouragement or cueing to eat, resulting in inadequate nutritional intake. On several occasions, the resident was observed sitting with her meal untouched, and staff failed to offer any assistance or alternative meal options. Interviews with staff, including a CNA and the registered dietitian, confirmed that the resident needed cueing and encouragement to eat, and alternatives should have been offered if she did not consume her meal. Despite this understanding, staff did not provide the necessary support during meal times, as evidenced by the observations. The resident's nutrition care plan, which highlighted the risk of inadequate nutrition and the need for monitoring and encouragement, was not adhered to, leading to the deficiency in care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below the acceptable threshold of 5%, with an observed error rate of 7.69%. This was due to two medication errors out of 26 opportunities. The errors were identified during an observation of a registered nurse (RN) administering medications to a resident. The medications involved were Aspirin EC and Lisinopril, both scheduled to be administered between 7:00 a.m. and 11:00 a.m. However, the RN administered these medications at 11:39 a.m., which was 39 minutes past the allowed administration time. The RN explained that the delay was caused by the need to re-approach a resident who was having a difficult day, which slowed down the medication administration process. During interviews, the interim director of nursing (IDON) and the nursing home administrator (NHA) expressed surprise at the late administration, noting that the RN was well-liked by residents and spent considerable time with them. The facility's policy on medication administration times was reviewed, confirming the scheduled times for medication passes.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored in one of the two medication refrigerators, specifically the Pine Ridge medication refrigerator. Observations revealed that the padlock on this refrigerator was repeatedly found unlocked on multiple occasions, even when the nurse's station was unattended. The refrigerator contained multiple doses of insulin and eye drops, and a black lock box inside the refrigerator was not adequately secured. During these times, there were non-facility employees and residents in close proximity to the unlocked refrigerator, posing a potential risk for unauthorized access to medications. Interviews with staff highlighted issues with the locking mechanisms. A registered nurse (RN) admitted to not knowing the code for the lock on the refrigerator and mentioned difficulties with the lock on the medication box inside. The Nursing Home Administrator (NHA) acknowledged that staff had reported difficulties with the locks, which may have contributed to the refrigerator being left unlocked. However, the NHA had not addressed these concerns prior to the survey observations.
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 11 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
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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 | 0.4 mi | ★★★★★ | 1 | 0 |
| Canon Lodge Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Hildebrand Care Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Progressive Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Bruce Mccandless Co State Veterans Nursing Home | 8.6 mi | ★★★★★ | 5 | 1 |
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