Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rock Creek Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident who was dependent on staff for wheelchair mobility was transported without foot pedals attached to the wheelchair, resulting in her feet catching on a rug and causing a fall that led to a cervical spine fracture and other injuries. The staff failed to ensure the use of required wheelchair safety equipment during transport, despite the resident's high risk for falls and severe cognitive impairment.
A resident with a history of hypertension experienced a fall with head injury and subsequently had persistently elevated blood pressure readings for over four hours. Despite repeated high BP measurements, the physician was not notified in a timely manner and no intervention was implemented until hours later, contrary to facility policy and professional standards. The resident was eventually transferred to the hospital with critically high blood pressure.
A resident with multiple chronic conditions and severe cognitive impairment did not have physician's progress notes available in the EMR after a certain date. The DON confirmed that previous physician documentation was kept in a separate system and not integrated into the facility's EMR, resulting in incomplete medical records at the time of survey.
Failure to Ensure Wheelchair Safety Equipment Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for wheelchair mobility was transported without the foot pedals attached to her wheelchair. The staff failed to ensure that the foot pedals, which are necessary for safe wheelchair transport, were in place. As a result, the resident was unable to rest her feet on the pedals while being moved from the dining room to her room. During this transport, the resident's foot or feet caught on a rug, causing her to fall forward out of the wheelchair and strike her head on the floor. The incident resulted in significant injuries to the resident, including a cervical (C1) spine fracture, a laceration and hematoma on her forehead, and a bruise on her left hand. The resident was assessed as being severely cognitively impaired, dependent on staff for all activities of daily living, and unable to walk. She was at high risk for falls, as documented in her care plan, and required staff assistance for all mobility. The care plan included interventions such as anti-tippers on the wheelchair but did not specify the consistent use of foot pedals during transport. Staff interviews revealed that it was common practice for some staff to transport residents without foot pedals if the resident had previously demonstrated the ability to lift their feet when requested. However, in this case, the resident was unable to keep her feet off the floor, leading to the accident. The investigation confirmed that the wheelchair did not have foot pedals attached at the time of the fall, and the staff member involved had been trained in wheelchair safety. The lack of foot pedals directly contributed to the resident's fall and subsequent injuries.
Failure to Timely Notify Physician and Intervene for Hypertensive Crisis After Fall
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards following an acute change in condition. After a fall in which the resident struck her head and sustained a laceration with hematoma, the resident's blood pressure was found to be significantly elevated, with multiple readings above 180/90 mmHg over a period of more than four hours. Despite these persistently high blood pressure readings, the physician was not notified in a timely manner, and no interventions were implemented to address the hypertensive crisis until several hours after the initial event. The resident had a history of hypertension, diabetes mellitus, and Alzheimer's disease, and was assessed as severely cognitively impaired and dependent on staff for all activities of daily living. Following the fall, neurological assessments and vital signs were documented at regular intervals, consistently showing elevated blood pressure. The facility's policy required prompt notification of the physician and implementation of interventions for significant changes in a resident's condition, such as persistently high blood pressure. However, the physician was not contacted until over four hours after the initial high blood pressure readings were documented, at which point a new order for antihypertensive medication was obtained, but the medication was not administered. Staff interviews confirmed that the standard of care would have been to notify the physician promptly if high blood pressure persisted, and that medication to lower blood pressure was available in the facility's emergency supply. The delay in physician notification and intervention resulted in the resident being transferred to the hospital later that day, where her blood pressure remained critically high. The deficiency centers on the facility's failure to follow its own policy and professional standards for timely physician notification and intervention in response to an acute change in the resident's condition.
Physician Progress Notes Missing from EMR
Penalty
Summary
The facility failed to maintain complete and accessible medical records for a resident, specifically by not ensuring that physician's progress notes were available in the electronic medical record (EMR) after a certain date. Record review showed that there were no physician's progress notes in the resident's EMR after 1/15/25, making these records unavailable for review during the survey. The resident in question was over 65 years old, had diagnoses including high blood pressure, diabetes mellitus, and Alzheimer's disease, and was assessed as severely cognitively impaired and dependent on staff for all activities of daily living. During staff interviews, the DON confirmed the absence of physician's progress notes in the EMR after the specified date. It was explained that the previous physician documented in a system separate from the facility's EMR, and records could only be obtained by special request. The facility had recently changed physician providers and was in the process of ensuring that documentation would be available in the EMR moving forward. However, at the time of the survey, the required physician documentation was not present in the resident's health record.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monte Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colorado Veterans Community Living Ctr At Homelake | 1.1 mi | — | 0 | 0 |
| River Valley Rehabilitation And Healthcare Center | 14.3 mi | — | 0 | 0 |
| San Luis Care Center | 14.4 mi | — | 0 | 0 |
| Evergreen Nursing Home | 14.7 mi | — | 2 | 0 |
| Rio Grande Rehabilitation And Healthcare Center | 23.2 mi | — | 15 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.