900 S 12th St., Rocky Ford, CO 81067 · Otero County · (719) 254-3314
101 certified beds, about 78 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1987
CMS Care Compare ratings, data as of September 1, 2026 · CCN 065235 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 18, 2024, inspectors cited 7 health deficiencies (the Colorado average is 8.7, the national average 9.2).
Of 24 health citations since September 2021, 4 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $10,033 in the last three years; the largest was $10,033, and the latest is dated April 18, 2024.
Nurses and nurse aides worked 3.36 hours per resident per day, against 3.72 across Colorado and 3.86 nationally. Registered nurses accounted for 0.56 of those hours.
44.0% of nursing staff left within the year CMS measured (Colorado average 47.1%).
CMS links it to Madison Creek Partners, an affiliated group of 13 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 24 health citations on file.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#4 and #6) of four residents reviewed for abuse out of seven sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #4 from physical abuse by Resident #5; and, -Protect Resident #6 from physical abuse by Resident #2.
Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the facility.
Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 28 of 55 resident rooms. Specifically, the facility failed to ensure: -The walls, ceilings, baseboards and floors were properly maintained; -The resident's rooms were cleaned and free of mice feces, flies; and, -The wooden handrails in the hallways were cleaned and free of wood splinters.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for three (#3, #2 and #7) of four residents reviewed for supplemental oxygen use out of 10 sample residents. Specifically, the facility failed to: -Administer oxygen in accordance with the physician's order for Resident #3 and #2; and, -Ensure a physician's order was in place for Resident #7's continuous use of oxygen.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#13) of three residents reviewed for accidents/hazards out of 28 samples residents. Resident #13 had been evaluated and determined to be a supervised smoker, which included she was not able to keep smoking supplies with her. The supplies were to be kept and monitored by the facility. During the scheduled smoke breaks, the facility would provide the resident with the cigarette and light the cigarette with a lighter. On 3/29/24 at 12:30 a.m. certified nurse aide (CNA) #8 heard screams coming from Resident #13's room. When she went in the room to check on Resident #8 she found the dressing on her lower left leg on fire. [...]
Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure the kitchen was clean and sanitary; and, -Ensure food was held at appropriate temperatures.
Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #9, CNA #11, CNA #12, CNA #13 and CNA #14.
Inspectors wroteBased on record review and interviews, the facility failed to notify the provider according to physician orders for one (#29) of three residents reviewed for unnecessary medications out of 28 sample residents. Specifically, the facility failed to notify and document Resident #29's elevated blood sugar levels to the provider as directed on the physician's order.
Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for one (#8) of five residents reviewed for ADL care out of 28 sample residents. Specifically, the facility failed to ensure Resident #8 received oral and personal hygiene daily. A. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot), unspecified fracture of lower end of right tibia (larger bone of the two lower leg bones) and multiple sclerosis (deterioration of the nerves). The 12/1/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. [...]
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#40) of three residents out of 28 sample residents who required respiratory care were provided such care and services consistent with professional standards of practice. Specifically, the facility failed to ensure Resident #40's supplemental oxygen was on the correct ordered liter flow per the physician's order.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of two medication carts. Specifically, the facility failed to: -Discard an expired Anoro inhaler; -Date an Anoro inhaler when opened; and, -Date a Lantus insulin pen when opened.
Inspectors wroteBased on interviews and record review, the facility failed to ensure three (#2, #3 and #5) out of nine residents reviewed for abuse were kept free from abuse out of nine sample residents. Specifically, the facility failed to: -Prevent a resident-to-resident altercations between Resident #1 and #2; -Prevent a resident-to-resident altercation between Resident #3 and #4; and, -Prevent a resident-to-resident altercation between Resident #5 and #6.
Inspectors wroteBased on record review and interviews, the facility failed to ensure level I and level II preadmission screening and resident review (PASRR) were completed for four (#31, #6, #64 and #68) out of 31 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #31, with a known psychological disorder, was properly assessed with a PASRR level I assessment; -Ensure Resident #64 and #68 had a level II PASRR in place; and, -Follow level II PASRR recommendations for Resident #6.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#5 and #43) of five out of 31 sample residents. Specially, the facility failed to: -Provide person centered activities for Resident #5 and Resident #43, who resided on the secured unit; and, -Provide meaningful and engaging activities for residents residing on the secured unit.
Inspectors wroteBased on interviews and record review, the facility failed to conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests for six (#74, #17, #9, #16, #73 and #56) of six residents reviewed out of 31 sample residents. Specifically, the facility failed to document in the resident records the results of COVID-19 tests for Resident #74, #17, #9, #16, #73 and #56.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#34, #62 #65 and #69) residents involved in three facility reported incidents on the South unit out of 46 sample residents. The facility failed to prevent an altercation between Resident #65 and Resident #34. Resident #34 was physically abused by Resident #65, which resulted in Resident #34 requiring hospital treatment where he received 12 staples to his head and medication for pain. Resident #62 was physically abused by Resident #34. Resident #34 pushed Resident #62's wheelchair into a wall resulting in Resident #62's bilateral lower extremities making contact with the wall. Resident #34 also made a comment he wanted to break Resident #62's legs. [...]
Inspectors wroteBased on record review, interviews and observations, the facility failed to ensure one (#60) of three residents reviewed for post surgical wounds and monitoring out of 46 sample residents received treatment, care and monitoring in accordance with professional standards of practice. Specifically, the facility failed to monitor Resident #60's new post surgical wound and clinically monitor changes in vital signs timely for which she required rehospitalization. Resident #60 admitted to the facility on [DATE] and readmitted on [DATE] with an Intra-abdominal and pelvic mass (which required surgical repair with staples). [...]
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#34, #62 #65, #50 and #69) of five out of 46 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #65's dementia care services to address triggered physically aggressive behavior in order to prevent physical altercations with other residents on the secured unit. The facility was aware Resident #65 had a diagnosis of dementia and occasionally displayed episodes of verbal and physical aggression. [...]
Inspectors wroteBased on interviews and record review, the facility failed to provide required dementia training for the facility staff for 12 certified nurse aides (CNAs) out of 12 CNAs reviewed. Specifically, the facility failed to provide the required in-service training on dementia management for certified nurse aides #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12. Cross-reference F744 for treatment/services dementia
Inspectors wroteBased on observations, interview and record review, the facility failed to ensure one (#18) of three residents reviewed for restraints out of 46 sample residents was free from physical restraints imposed for purposes of convenience. Specifically, the facility failed to ensure a resident was not restrained while in the dining room.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that all allegations involving physical abuse were reported immediately to the specified appropriate administrative staff for two (#34 and #62) of four out of 46 sample residents. Specifically, the facility staff failed to report the physical abuse of Resident #62 from Resident #34 in a timely manner to the abuse coordinator, and therefore did not report to the State Agency in a timely manner.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, for one (#67) of two residents reviewed of 46 sampled residents. Specifically, the facility failed to ensure Resident #67's left hand splint was applied for contracture management per physician's orders.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment was free from accident hazards for for one (#74) of one resident out of 46 sample residents. Specifically, the facility failed to prevent Resident #74 from eloping (run away intentionally) from the facility.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#29) of three residents reviewed for oxygen therapy out of 46 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #29.
29 fire safety citations on file: 12 on April 18, 2024, 5 on December 29, 2022, 12 on September 16, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| April 18, 2024 | Fine | $10,033 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Colorado | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.36 | 3.72 | 3.86 |
| Registered nurses | 0.56 | 0.82 | 0.69 |
| All nursing staff on weekends | 3.02 | 3.29 | 3.42 |
| Nurse aides | 2.18 | ||
| Licensed practical nurses | 0.62 | ||
| Nursing staff turnover (share who left in a year) | 44.0% | 47.1% | 45.8% |
| Registered nurse turnover | 46.7% | 44.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 2.90 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.50 on weekdays and 3.02 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 9.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.29 in April to June 2025 to 3.36 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.36 | 0.56 | 3.50 | 3.02 | 9.5% | 0 of 90 | 78 |
| Oct to Dec 2025 | 3.53 | 0.61 | 3.60 | 3.33 | 7.7% | 0 of 92 | 73 |
| Jul to Sep 2025 | 3.41 | 0.61 | 3.53 | 3.10 | 3.3% | 0 of 92 | 74 |
| Apr to Jun 2025 | 3.29 | 0.67 | 3.42 | 2.96 | 2.6% | 0 of 91 | 81 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Colorado, Jan to Mar 2026 | 3.59 | 0.76 | 3.75 | 3.18 | 5.9% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Colorado, all employers | |||
| CNAs (nursing assistants) | $22.78 | $21.42 to $24.00 | 22,240 |
| LPNs and LVNs | $35.52 | $29.76 to $38.37 | 4,920 |
| Registered nurses | $48.20 | $40.67 to $52.37 | 54,490 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Colorado | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 10.4 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.6 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.3 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.8 | 3.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.4 | 13.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.4 | 3.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 35.6 | 20.0 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 1.4 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.0 | 1.7 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Pioneer Health Care Center's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Colorado: 39 better, 8 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 9 eligible stays.
12.1% this home
No different from the national rate
US median of homes 10.7% · Colorado: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 36 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Colorado: 4 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 18 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Colorado65.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 15 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Colorado0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 17 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Colorado0.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 17 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Colorado99.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 10 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: 12TH STREET OPERATIONS, LLC. CMS links this home to Madison Creek Partners, a group of 13 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Chief Joseph Trail, LLC | 5% or greater direct ownership interest | Organization | 100% | 03/02/2026 |
| Tippet, LLC | 5% or greater indirect ownership interest | Organization | 03/02/2026 | |
| White Canyon, LLC | 5% or greater indirect ownership interest | Organization | 03/02/2026 | |
| Clegg, Michael | 5% or greater indirect ownership interest | Individual | 03/02/2026 | |
| Clegg, Michael | Managing control - governing body | Individual | 06/26/2023 | |
| Ikerd, John | Managing control - governing body | Individual | 03/02/2026 | |
| Madison Creek Partners LLC | Operational/managerial control | Organization | 07/01/2016 | |
| Christensen, Covey | Operational/managerial control | Individual | 07/01/2016 | |
| Clegg, Michael | Operational/managerial control | Individual | 06/26/2023 | |
| Cook, Cameron | Operational/managerial control | Individual | 02/27/2025 | |
| Hopkins, Amber | Operational/managerial control | Individual | 12/01/2021 | |
| Ikerd, John | Operational/managerial control | Individual | 04/25/2022 | |
| Shepherd, David | Operational/managerial control | Individual | 06/01/2022 | |
| Madison Creek Partners LLC | Adp of the SNF | Organization | 03/30/2026 | |
| Christensen, Covey | Adp of the SNF | Individual | 07/01/2016 | |
| Clegg, Michael | Adp of the SNF | Individual | 06/26/2023 | |
| Cook, Cameron | Adp of the SNF | Individual | 02/27/2025 | |
| Hopkins, Amber | Adp of the SNF | Individual | 12/01/2021 | |
| Ikerd, John | Adp of the SNF | Individual | 04/25/2022 | |
| Shepherd, David | Adp of the SNF | Individual | 06/01/2022 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Colorado. NursingHomeClear cannot take or act on complaints.