Inspection Reports for
Rock Creek Rehabilitation and Healthcare Center
2277 EAST DR, MONTE VISTA, CO, 81144-9330
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
31% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 11, 2025
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to provide appropriate treatment and care, ensure accident hazard prevention, and maintain resident health records, specifically related to Resident #1's fall and subsequent medical care.
Complaint Details
The investigation was complaint-driven, focusing on Resident #1's fall, delayed physician notification for high blood pressure, wheelchair safety failures, and incomplete medical records. Resident #1 sustained serious injury and subsequently passed away in hospice care.
Findings
The facility failed to timely notify the physician and intervene for high blood pressure after Resident #1's fall, failed to ensure wheelchair safety by not attaching foot pedals leading to a fall causing a cervical spine fracture, and failed to maintain complete physician progress notes in the electronic medical record.
Deficiencies (3)
F684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, specifically failing to timely notify the physician and intervene for Resident #1's high blood pressure after a fall.
F0689: The facility failed to ensure adequate supervision and accident hazard prevention, resulting in Resident #1 falling from a wheelchair without foot pedals, causing a cervical spine fracture.
F0842: The facility failed to maintain physician progress notes in Resident #1's electronic medical record after 1/15/25, impairing documentation of care.
Report Facts
Blood pressure readings: 190
Blood pressure readings: 208
C1 spine fracture displacement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding post-fall assessments and delayed physician notification for high blood pressure. |
| CNA #1 | Certified Nurse Aide | Interviewed about wheelchair safety and foot pedal usage. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding facility policies, post-fall assessments, and corrective actions. |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Interviewed about wheelchair assessments and maintenance responsibilities. |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 8, 2024
Visit Reason
The inspection was a routine survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to respond to resident grievances, failure to post required state agency contact information, failure to maintain a sanitary environment, inadequate discharge planning, failure to provide appropriate contracture prevention, inadequate fall prevention and supervision, failure to maintain required RN staffing hours, incomplete nurse aide performance reviews, improper medication labeling, and failure to ensure pneumococcal vaccinations were offered or documented.
Deficiencies (10)
F 0565: The facility failed to provide response, action, and rationale to residents involved in group grievances concerning staff, laundry, and housekeeping.
F 0574: The facility failed to post names, addresses, and telephone numbers of all pertinent state regulatory and informational agencies and advocacy groups.
F 0584: The facility failed to maintain a sanitary, orderly, and comfortable environment by not ensuring blinds were intact in six resident rooms.
F 0660: The facility failed to develop and implement an effective discharge planning process focused on Resident #13's discharge goals.
F 0688: The facility failed to ensure a carrot contracture prevention device was placed according to physician orders for Resident #23.
F 0689: The facility failed to ensure a safe environment and adequate supervision to prevent accidents for Residents #16 and #4, resulting in multiple falls and injuries.
F 0727: The facility failed to have a registered nurse scheduled for eight consecutive hours a day on a consistent basis from 11/1/23 to 2/5/24.
F 0730: The facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of these reviews for three certified nurse aides.
F 0761: The facility failed to date a multi-use vial of tuberculin when opened, risking medication safety.
F 0883: The facility failed to ensure Residents #13, #3, #16, and #20 were offered and/or received pneumococcal immunization and lacked documentation of offers or refusals.
Report Facts
Falls: 17
RN staffing deficiency days: 19
Resident rooms with broken blinds: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication labeling and carrot splint application |
| Director of Nursing | DON | Interviewed regarding RN staffing, nurse aide performance reviews, medication labeling, fall prevention, and grievance handling |
| Certified Nurse Aide #2 | CNA | Interviewed regarding carrot splint application for Resident #23 |
| Certified Nurse Aide #3 | CNA | Interviewed regarding fall prevention for Resident #16 |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding fall prevention for Resident #16 |
| Nursing Home Administrator | NHA | Interviewed regarding grievance handling and pneumococcal vaccine documentation |
| Social Services Consultant | SSC | Interviewed regarding grievance handling and discharge planning |
| Nurse Practitioner | NP | Interviewed regarding fall prevention and pneumococcal vaccine policies |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 10, 2019
Visit Reason
Routine inspection of Rock Creek Rehabilitation and Healthcare Center to assess compliance with healthcare regulations including resident care, infection control, medication management, and facility safety.
Findings
The facility had multiple deficiencies including failure to provide required Medicare non-coverage notices, incomplete PASARR screenings, failure to follow physician orders for resident care, inadequate respiratory care, incomplete staff competency documentation, insufficient behavioral health care and monitoring, unsanitary food preparation and storage conditions, lack of antibiotic stewardship program, and ineffective pest control resulting in flies throughout the facility.
Deficiencies (10)
F582: Facility failed to provide Resident #135 or representative notice of Medicare non-coverage and appeal rights as required.
F645: Facility failed to update PASARR level II for Resident #4 after medication and PHQ-9 score changes.
F684: Facility failed to ensure Resident #133 wore Geri sleeves per physician orders, with no care plan for sleeve placement.
F695: Facility failed to provide ordered oxygen liter flow for Resident #26 and lacked physician order for oxygen for Resident #4.
F726: Facility failed to complete competency records for all certified nurse aides.
F740: Facility failed to monitor and document behaviors and provide individualized behavioral interventions for Residents #4, #132, and #24.
F744: Facility failed to provide person-centered dementia care and effective behavior management for Residents #26 and #21.
F812: Facility failed to maintain cutting boards free of deep scratches and stains and failed to store food off the floor.
F881: Facility failed to implement an antibiotic stewardship program and failed to assess appropriate antibiotic use for Resident #1.
F925: Facility failed to maintain an effective pest control program, resulting in flies in the kitchen, dining room, resident rooms, and hallways.
Report Facts
Residents reviewed: 18
Behavior episodes: 21
Behavior episodes: 15
Behavior episodes: 8
Behavior episodes: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #3 | LPN | Interviewed regarding failure to ensure Geri sleeves applied to Resident #133 |
| Certified nurse aide #4 | CNA | Interviewed regarding Resident #133 Geri sleeves and Resident #4 behaviors |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including respiratory care, antibiotic stewardship, and behavior management |
| Dietary Manager | DM | Interviewed regarding cutting board condition and food storage |
| Maintenance Director | MTCE | Interviewed regarding pest control and fly infestation |
| Social Services Director | SSD | Interviewed regarding PASARR screening, behavior monitoring, and dementia care |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 16, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for comprehensive care plans, accident hazard prevention, and staff training in a nursing home.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents at risk of falls and pressure injuries. The environment posed accident hazards due to unsafe modified call light cords. Additionally, the facility failed to provide required in-service training for certified nurse aides, including dementia and abuse prevention training.
Deficiencies (4)
F 0656: The facility failed to develop and implement a comprehensive care plan for Resident #8's increased risk and history of falling and for Resident #22's potential for pressure injuries.
F 0657: The facility failed to revise Resident #26's care plan to include interventions to prevent pressure injuries in multiple locations beyond an existing injury.
F 0689: The facility failed to ensure a homemade/modified call light cord could be used safely by Resident #22, creating a possible accident hazard.
F 0947: The facility failed to ensure 10 out of 10 certified nurse aides received the required 12 hours of annual in-service training including dementia management and resident abuse prevention.
Report Facts
Residents reviewed for comprehensive care plans: 15
Residents affected by care plan deficiencies: 3
Certified nurse aides reviewed: 10
Certified nurse aides lacking required training: 9
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