Cycle 1
Health 2024-02-08 · Fire 2024-02-08
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Monte Vista, CO
Rock Creek Rehabilitation And Healthcare Center
2-star overall rating with 2-star inspections with $42,008 in total fines with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2277 East Dr, Monte Vista, CO
(719) 852-5138
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Centennial Healthcare
Operator or chain grouping
Approved since
1991-06-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.17
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.63
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.03
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
2.82
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 6.55% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.56% |
8.2%
2.6 pts worse
|
Numerator 3 · Denominator 54 |
| Staff flu vaccination coverage | 96.23% |
42%
54.2 pts better
|
Numerator 51 · Denominator 53 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
93.5%
4 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 100.0% · Q3 97.0% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
94.7%
0.9 pts worse
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.4%
0.7 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 6.1% · Q4 6.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 53.9% |
7.4%
46.5 pts worse
|
11.4%
42.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 82.8% · Q3 53.1% · Q4 57.1% · 4Q avg 53.9% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.0%
0.8 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 9.1% · Q4 3.3% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
11.2%
3.8 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 6.2% · Q3 9.1% · Q4 3.3% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.0% |
20.6%
12.4 pts worse
|
16.7%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q3 32.1% · Q4 39.1% · 4Q avg 33.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.5% |
15.2%
5.7 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 13.5% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
14.6%
0.5 pts worse
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 27.6% · Q3 10.3% · Q4 8.0% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.5%
0.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
22.4%
2.4 pts better
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 18.3% · Q3 20.8% · Q4 16.0% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
3.7%
2.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 2.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.0% |
76.4%
3.6 pts better
|
81.7%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 90.0% · 4Q avg 80.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-10 · Fire 2019-10-10
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2018-08-16 · Fire 2018-08-16
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-02-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-02-08
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-02-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-02-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-08
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-03-07
F · Potential for more than minimal harm
2019-10-10
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-12-18
F · Potential for more than minimal harm
2019-10-10
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-11-05
F · Potential for more than minimal harm
2019-10-10
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-12-18
F · Potential for more than minimal harm
2019-10-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-12-18
F · Potential for more than minimal harm
2019-10-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-11-09
F · Potential for more than minimal harm
2019-10-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-10
F · Potential for more than minimal harm
2019-10-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-09
E · Potential for more than minimal harm
2019-10-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-10
D · Potential for more than minimal harm
2019-10-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-09
D · Potential for more than minimal harm
2019-10-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-02
F · Potential for more than minimal harm
2018-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-09-14
F · Potential for more than minimal harm
2018-08-16
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2018-09-14
E · Potential for more than minimal harm
2018-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-09-11
C · Minimal harm
2018-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-09-11
Inspection history
Recent health citations
G · Actual harm
2025-12-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-12-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-29
G · Actual harm
2024-02-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-09
E · Potential for more than minimal harm
2024-02-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-08
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-08
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-04
C · Minimal harm
2024-02-08
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-02-28
F · Potential for more than minimal harm
2019-10-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-11-20
F · Potential for more than minimal harm
2019-10-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-11-05
F · Potential for more than minimal harm
2019-10-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-11-05
E · Potential for more than minimal harm
2019-10-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-05
D · Potential for more than minimal harm
2019-10-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-11-05
D · Potential for more than minimal harm
2019-10-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-11-05
D · Potential for more than minimal harm
2019-10-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-05
D · Potential for more than minimal harm
2019-10-10
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2019-11-05
D · Potential for more than minimal harm
2019-10-10
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-11-05
F · Potential for more than minimal harm
2018-08-16
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2018-09-19
D · Potential for more than minimal harm
2018-08-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-09-10
D · Potential for more than minimal harm
2018-08-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2018-09-17
D · Potential for more than minimal harm
2018-08-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-09-10
Penalties and ownership
What sits behind the stars
$14,015
2025-12-10
Fine
Fine · fine $14,015
Fine
$27,993
2024-02-08
Fine
Fine · fine $27,993
Fine
Ownership
Centennial Ii Colorado Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Centennial Ii Tbd Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Centennial Mn Tr I
5% Or Greater Indirect Ownership Interest · Organization
Centennial Ms Trust I
5% Or Greater Indirect Ownership Interest · Organization
Centennial Yf Trust I
5% Or Greater Direct Ownership Interest · Organization
Deacon, Alicia
Operational/Managerial Control · Individual
Gottlieb, Refoel
Operational/Managerial Control · Individual
Gotts Consulting Colorado LLC
Operational/Managerial Control · Organization
Pandit, Kiran
Operational/Managerial Control · Individual
Snarl Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Colorado Veterans Community Living Ctr At Homelake
Monte Vista, CO
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
River Valley Rehabilitation And Healthcare Center
Del Norte, CO
2-star overall rating with 2-star inspections with abuse icon flag with $14,768 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
San Luis Care Center
Alamosa, CO
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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