Rock Creek Rehabilitation and Healthcare Center
2277 East Dr, Monte Vista, CO 81144 · Rio Grande County · 60 certified beds · avg 34 residents/day · certified since Jun 5, 1991
Abuse citation flag (CMS)
Part of chain: CENTENNIAL HEALTHCARE (8 facilities, chain avg rating 2.4★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 20, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 15, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 11, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 9, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Feb 8, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 9, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (31)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 20, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 20, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 20, 2026 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| May 20, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 20, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| May 20, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 20, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| May 20, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Dec 11, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Feb 8, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 8, 2024 | C · Minimal risk, facility-wide | The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss. |
| Oct 10, 2019 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Oct 10, 2019 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Oct 10, 2019 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Oct 10, 2019 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 10, 2019 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Oct 10, 2019 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Oct 10, 2019 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 10, 2019 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Oct 10, 2019 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Oct 10, 2019 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 10 | 0 | F |
| 2024 | 10 | 1 | G ▲ |
| 2025 | 3 | 1 | G ▲ |
| 2026 | 8 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $37,103.
| Date | Type | Amount / length |
|---|---|---|
| Dec 10, 2025 | Fine | $9,110 |
| Feb 8, 2024 | Fine | $27,993 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 0.00 | 3.89 | 3.95 | — |
| Registered Nurse hours | 0.00 | 0.86 | 0.69 | — |
| Weekend total nurse staffing | 0.00 | 3.44 | 3.50 | — |
| Weekend RN hours (not acuity-adjusted) | 0.00 | 0.61 | 0.48 | — |
| Total nursing staff turnover (%) | 0.0 | 47.1 | 45.8 | — |
| RN turnover (%) | 0.0 | 44.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 0.00, RN 0.00, weekend 0.00. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Centennial II Colorado Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | — | 05/01/2024 |
| Centennial II TBD Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 05/01/2024 |
| Centennial MN Tr I | Organization | 5% or Greater Indirect Ownership Interest | — | 05/01/2024 |
| Centennial Yf Trust I | Organization | 5% or Greater Direct Ownership Interest | — | 05/01/2024 |
| Snarl Family Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 05/01/2024 |
| Centennial MN Tr I | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Centennial Ms Trust I | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Centennial Yf Trust I | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Deacon, Alicia | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Deacon, Alicia | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Gottlieb, Refoel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2024 |
| Gottlieb, Refoel | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Gottlieb, Refoel | Individual | Trustee of the SNF | NOT APPLICABLE | 05/01/2024 |
| Gottlieb, Refoel | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Gotts Consulting Colorado LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Gotts Consulting Colorado LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Pandit, Kiran | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2025 |
| Pandit, Kiran | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Colorado Veterans Community Living Ctr at Homelake | 1.1 mi | Monte Vista, CO | ★★★★★ | 5/5 | |
| River Valley Rehabilitation and Healthcare Center | 14.3 mi | Del Norte, CO | ★★☆☆☆ | 2/5 | abuse |
| San Luis Care Center | 14.4 mi | Alamosa, CO | ★★★★☆ | 4/5 | |
| Evergreen Nursing Home | 14.7 mi | Alamosa, CO | ★★☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 065291.