The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited December 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
ROCK CREEK REHABILITATION AND HEALTHCARE CENTER
MONTE VISTA, CO · Medicare-certified · 60 beds
Needs attention
For-profitChain member
2 of 5 overall
2 out of 5 stars overall. This facility has a 2-star health inspection rating, 3-star staffing, and 4-star quality measures rating; reported nurse staffing is 3.36 hours per resident per day, below the federal benchmark of 4.1, and it had $14,015 in fines in the last 24 months with a recent federal penalty.
Facility ratings
Health inspections
Staffing
3.3632 hrs/resident/day
Quality measures
Last inspection: December 11, 2025Penalties, last 24 months: $14,015recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.3632.
Staffing detail
- Registered nurses
- 1.03
- Licensed practical nurses
- 0.60
- Nurse aides
- 1.73
- Weekend nursing
- 2.93
Hours per resident per day.
Total staff turnover: 30%
Registered nurse turnover: 13%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
36.4%Improving
Residents with a fall causing major injury
6.3%Worsening
Residents with pressure ulcers (bedsores)
2.7%Worsening
Residents with a urinary tract infection
0.8%Steady
Residents who lost too much weight
6.5%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
13%Improving
Residents whose ability to walk got worse
10.6%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
5.6%Improving
Short-stay residents newly given an antipsychotic
0%Steady
Residents with a long-term catheter
0%Steady
Residents with new or worsening incontinence
16%Improving
Residents with depressive symptoms
64.7%Improving
Long-stay residents given the seasonal flu vaccine
93.8%Steady
Long-stay residents given the pneumonia vaccine
98.4%Worsening
Short-stay residents given the pneumonia vaccine
89.2%Steady
What the inspectors found
The home failed to ensure nurses and nurse aides had the needed skills to care for each resident and support their well-being. Cited October 2019 — widespread issue, potential for harm.
View the original federal record
F-Tag 726 — 42 CFR §483.35 — S/S: F
The home failed to monitor antibiotic use properly. Cited October 2019 — widespread issue, potential for harm.
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F-Tag 881 — 42 CFR §483.80 — S/S: F
The nursing home failed to make sure it had a pest control program to prevent or deal with mice, insects, and other pests. Cited October 2019 — widespread issue, potential for harm.
View the original federal record
F-Tag 925 — 42 CFR §483.90 — S/S: F
The home failed to ensure nurse aides had the skills and training needed to care for residents safely, including dementia care and abuse prevention. Cited August 2018 — widespread issue, potential for harm.
View the original federal record
F-Tag 947 — 42 CFR §483.95 — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $14,015 was recorded.
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 2 fines · $42,008 in total fines.
- $14,015
Federal fine
Dec 10, 2025
- $27,993
Federal fine
Feb 8, 2024
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of CENTENNIAL HEALTHCARE · 8 homes · 2.5 stars avg
- Occupancy
- 32.8 residents on an average day (55% of 60 beds)
- Medicare history
- Certified for 35 years
The most recent standard health inspection was more than two years ago.
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.