Inspection Reports for
Hildebrand Care Center
1401 PHAY AVE, CANON CITY, CO, 81212-2303
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 3
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to psychotropic medication use, resident transfer safety, and medication storage practices at the nursing home.
Findings
The facility was found deficient in monitoring and documenting the use of psychotropic medications beyond the 14-day limit for one resident, ensuring safe transfer procedures for two residents requiring two-person assistance, and proper labeling and storage of medications on multiple medication carts.
Deficiencies (3)
F 0605: The facility failed to ensure the physician's order for Resident #7's PRN lorazepam was reevaluated and justified beyond the 14-day limit as required by regulations.
F 0689: The facility failed to ensure adequate supervision and proper transfer techniques for Residents #10 and #39, resulting in transfers not following the two-person assistance orders.
F 0761: The facility failed to properly label medications with dates opened, discard expired medications, label medications with resident names, and maintain medication carts free of loose pills.
Report Facts
Residents reviewed for psychotropic medication use: 51
Residents reviewed for accidents: 51
Residents reviewed for medication storage: 4
Loose pills found: 35
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Dec 4, 2025
Visit Reason
The inspection was conducted due to complaints regarding inadequate supervision and improper transfer techniques for residents requiring assistance.
Complaint Details
The complaint investigation substantiated that agency CNAs transferred residents #10 and #39 alone despite care plans requiring two-person assistance. Both residents were transferred improperly, but no injuries were sustained. The agency CNAs were educated or removed from the facility following the incidents.
Findings
The facility failed to ensure two residents (#10 and #39) were transferred according to their care plans, resulting in improper one-person transfers instead of required two-person assistance. Both incidents involved agency CNAs not following proper transfer procedures, though no injuries were reported.
Deficiencies (2)
F 0689: The facility failed to ensure residents received adequate supervision to prevent accidents by not following proper transfer procedures for Resident #10, who required two-person assistance with a gait belt and transfer pole but was transferred alone causing knee pain.
F 0689: The facility failed to ensure Resident #39 was transferred with two-person assistance as required; an agency CNA transferred the resident alone using a gait belt, violating the care plan and facility procedures.
Report Facts
Residents reviewed for accidents: 51
Residents affected: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a choking incident involving Resident #1 who was served the wrong diet texture, resulting in severe harm and death.
Complaint Details
The complaint investigation confirmed the deficient practice had been corrected prior to the onsite survey and the facility was in substantial compliance at the time of the survey from 4/16/24 to 4/17/24.
Findings
The facility failed to ensure Resident #1 received the correct physician-ordered mechanical soft diet, leading to a choking episode, hospitalization, severe hypoxic brain injury, and death. The facility implemented corrective actions including staff education, a new diet card system, and ongoing meal service audits.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders, resulting in Resident #1 being served the wrong diet texture which caused choking and subsequent severe harm.
Report Facts
Residents Affected: 1
Oxygen saturation: 67
Survey completion date: Apr 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided corrective action plan and interviewed regarding the incident |
| Director of Nursing | DON | Interviewed about the choking incident and facility response |
| Dietary Manager | DM | Interviewed about dietary practices, education, and new diet card system |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 16, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, and medication management at Hildebrand Care Center.
Findings
The facility was found deficient in multiple areas including failure to honor resident medication requests timely, inadequate grievance resolution, failure to assist residents with vision aids, inadequate supervision of residents at risk of elopement, failure to provide oxygen therapy as ordered, and improper storage and security of medications.
Deficiencies (6)
F 0561: The facility failed to ensure Resident #37 received anti-nausea medication in a timely manner upon request, resulting in a delay of over an hour.
F 0585: The facility failed to document and resolve a grievance regarding Resident #6's missing facial cream, and staff did not complete a grievance form or investigate the complaint properly.
F 0685: The facility failed to ensure Resident #121 was assisted to wear his glasses, impacting his vision care.
F 0689: The facility failed to ensure agency staff were aware of Resident #121's history and risk of elopement, resulting in inadequate supervision and alarm response.
F 0695: The facility failed to ensure Residents #20 and #64 received oxygen therapy at the physician-ordered liter flow rates, with Resident #20 receiving less oxygen and Resident #64 not receiving oxygen continuously as ordered.
F 0761: The facility failed to ensure medication carts were locked when unattended and controlled medication lock boxes in refrigerators were not permanently affixed, risking unauthorized access.
Report Facts
Residents in sample: 31
Deficiencies cited: 6
Medication delay: 65
Oxygen liter flow ordered: 4
Oxygen liter flow observed: 2
Oxygen liter flow ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication delay finding for Resident #37 |
| CNA #1 | Certified Nurse Aide | Named in medication delay finding for Resident #37 |
| RN #2 | Registered Nurse | Named in medication delay finding for Resident #37 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication delay, grievance process, vision care, elopement risk, oxygen therapy, and medication storage |
| RN #3 | Registered Nurse | Named in grievance finding for Resident #6 |
| ASSD | Assistant Social Services Director | Interviewed regarding grievance process for Resident #6 |
| SSD | Social Services Director | Interviewed regarding grievance process for Resident #6 |
| CNA #2 | Certified Nurse Aide | Named in vision and elopement risk findings for Resident #121 |
| CNA #3 | Certified Nurse Aide | Named in vision care finding for Resident #121 |
| LPN #4 | Licensed Practical Nurse | Named in oxygen therapy findings for Residents #20 and #64 |
| CNA #4 | Certified Nurse Aide | Named in oxygen therapy findings for Residents #20 and #64 |
| LPN #3 | Licensed Practical Nurse | Named in medication storage and security findings |
| RN #1 | Registered Nurse | Named in medication storage and security findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 6, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to prevent accidents and manage pain effectively for Resident #1, including investigation of falls and injury.
Complaint Details
The investigation was complaint-driven, focusing on Resident #1's falls and pain management. The complaint was substantiated with findings of inadequate fall prevention and pain management.
Findings
The facility failed to implement effective fall prevention interventions and delayed assessment and monitoring of injuries and pain for Resident #1 after multiple falls, resulting in a fractured hip and additional falls. Pain management was inadequate, with insufficient pain medication administration and documentation.
Deficiencies (2)
F 0689: The facility failed to ensure accident hazards were minimized and adequate supervision was provided, resulting in Resident #1 sustaining a fractured left hip from a fall on 2/1/23 and subsequent falls due to ineffective interventions and lack of proper transfer assistance.
F 0697: The facility failed to provide safe and appropriate pain management for Resident #1, who experienced severe pain after a fall and hip fracture, with inadequate pain assessments, ineffective medication administration, and lack of follow-up.
Report Facts
Falls: 8
Pain medication doses: 3
Pain scale rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in relation to failure to document pain assessments and x-ray orders after Resident #1's fall. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #1's transfer assistance needs and toileting assistance. |
| RN #2 | Registered Nurse | Interviewed about Resident #1's care and pain documentation practices. |
| DON | Director of Nursing | Interviewed about facility policies and follow-up on falls and pain management. |
| ADON | Assistant Director of Nursing | Interviewed about pain assessment and medication administration practices. |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 28, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with resident rights, medication regimen reviews, mail delivery, and other regulatory requirements at the nursing home.
Findings
The facility failed to honor residents' bathing preferences for four residents, failed to ensure timely mail delivery on Saturdays, and did not complete monthly drug regimen reviews by a licensed pharmacist for several residents in April 2022. A performance improvement plan was initiated for shower inconsistencies.
Deficiencies (3)
F 0561: The facility failed to provide routine bathing consistent with the preferences of four residents, resulting in missed or rescheduled showers over multiple weeks.
F 0576: The facility failed to ensure residents had reasonable access to send and receive mail during routine USPS hours, specifically failing to deliver mail on Saturdays.
F 0756: The facility failed to ensure a licensed pharmacist performed monthly drug regimen reviews for several residents in April 2022, missing medication reviews for at least four residents.
Report Facts
Residents reviewed for bathing preferences: 37
Residents affected by bathing deficiency: 4
Medication regimen review missed: 4
Shower opportunities vs. received for Resident #23: 8
Shower opportunities vs. received for Resident #23: 8
Shower opportunities vs. received for Resident #23: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided facility policies, shower logs, and interviewed regarding bathing and medication regimen review deficiencies | |
| Social Service Director (SSD) | Interviewed regarding resident complaints and shower scheduling | |
| Certified Nurse Aide (CNA) #2 | Interviewed about shower documentation and resident preferences | |
| Nursing Home Administrator (NHA) | Interviewed about mail delivery and shower deficiencies | |
| Facility Pharmacist (PH) | Interviewed about missed medication regimen reviews in April 2022 | |
| Business Office Manager (BOM) | Interviewed about mail delivery practices | |
| Director of Admissions and Activities (DAA) | Interviewed about mail delivery history and facility practices |
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