Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colorado Veterans Community Living Ctr At Homelake during CMS and state inspections, most recent first.
Two residents in the facility were administered blood pressure medications without prior assessment of vital signs, contrary to professional standards. One resident with Parkinson's disease and orthostatic hypotension received Metoprolol without checking pulse or blood pressure parameters. Another resident with diabetes and hypertension was given Amlodipine and Lisinopril without assessing vital signs. Staff interviews revealed inconsistent practices in monitoring vital signs before medication administration.
The facility failed to accurately document resuscitation choices for three residents. A resident's DNR status was not reflected in the physician's order despite being indicated on their MOST form. Another resident's MOST form was missing from the binder used in emergencies, and a third resident's MOST form was signed by their MPOA without discussion, despite the resident being cognitively intact.
The facility failed to protect a resident from abuse by another resident known to be physically aggressive. Despite interventions, repeated altercations occurred, resulting in multiple injuries to the victim. The facility's measures were ineffective in preventing further incidents.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice by not monitoring and assessing vital signs before administering blood pressure medications to two residents. Resident #15, an 80-year-old with Parkinson's disease, orthostatic hypotension, and syncope, was given Metoprolol without checking the pulse rate or reviewing the blood pressure parameters. The resident's blood pressure was recorded as 93/60 mmHg, but the nurse did not verify the pulse or consult the physician, as required by professional guidelines. Similarly, Resident #7, who has diabetes mellitus and hypertension, received Amlodipine and Lisinopril without an assessment of vital signs, including blood pressure and pulse. The nurse did not check the order for blood pressure parameters or review the resident's most recent vital signs before administering the medications. The facility's records did not document any parameters for when to hold these medications or when to notify the physician of irregular vital sign results. Interviews with staff revealed a lack of consistent practice in checking vital signs before administering medications. RN #2 stated that vital signs were only checked if the resident was symptomatic or if there were ordered parameters. The Director of Nursing acknowledged that blood pressure and pulse should be taken before administering such medications, even if no parameters were ordered, indicating a gap in adherence to professional standards of practice.
Deficiency in Documenting Resident Resuscitation Choices
Penalty
Summary
The facility failed to maintain complete and accurate documentation of resident resuscitation choices in the medical records for three residents. Resident #141, who was cognitively intact and had expressed a wish to be a Do Not Resuscitate (DNR) according to their Medical Orders for Scope of Treatment (MOST) form, did not have a corresponding physician's order documented in the electronic medical record (EMR). This oversight was identified during a MOST form audit conducted by the facility. Resident #13, who had severe cognitive impairment, had a physician's order for DNR status documented in their computerized physician orders (CPO). However, a comprehensive review of the facility's MOST form binder failed to reveal a completed MOST form for this resident. The facility's process during an emergency situation relied on the MOST binder, which was missing the original form for Resident #13. Resident #32, who was cognitively intact, had a MOST form indicating a DNR status signed by their medical power of attorney (MPOA). However, the form did not indicate that the decision was discussed with the resident, despite their cognitive ability to make their own decisions. Additionally, the resident's care plan did not identify their resuscitation wishes according to the MOST form.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to ensure that Resident #1 was protected from abuse by Resident #2, who was known to be physically aggressive. On 11/7/23, Resident #2 attacked Resident #1 while he was sleeping, causing multiple injuries including scratches, abrasions, and bruising. Despite the intervention to move Resident #2 to a different hall and keep him in the staff's line of sight, another altercation occurred on 1/3/24. During this second incident, Resident #2 was found holding Resident #1 by his shirt collar, resulting in Resident #1 sustaining a bloody nose, skin tears, abrasions, and a fractured finger. Resident #1 was sent to the hospital for evaluation and treatment. The facility's measures to protect Resident #1 were ineffective, as evidenced by the repeated altercations and injuries sustained by Resident #1. The facility's abuse policy, revised on 10/16/23, mandates the protection of residents from mistreatment, abuse, neglect, and exploitation by anyone, including other residents. However, the facility failed to implement effective measures to prevent Resident #2's aggressive behavior towards Resident #1. The initial intervention to keep Resident #2 in the staff's line of sight and move him to a different hall was insufficient, as demonstrated by the subsequent altercation on 1/3/24. Staff interviews revealed that there were no specific interventions or guidelines in place to prevent further altercations between the two residents. Resident #1, an 87-year-old with moderate cognitive impairment and dementia, preferred to stay in his room and had a history of verbal and physical behaviors. Resident #2, a 76-year-old with severe cognitive impairment and a history of physical aggression, exhibited behaviors such as yelling, cussing, and threatening staff. Despite these known behaviors, the facility did not have adequate interventions to manage Resident #2's aggression and protect Resident #1 from harm. The facility's failure to implement effective measures resulted in repeated incidents of abuse and injury to Resident #1.
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What surveyors actually found near you
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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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Illustrative
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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) |
|---|---|---|---|---|
| Rock Creek Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 16 | 0 |
| San Luis Care Center | 13.3 mi | ★★★★★ | 0 | 0 |
| Evergreen Nursing Home | 13.6 mi | ★★★★★ | 2 | 0 |
| River Valley Rehabilitation And Healthcare Center | 15.4 mi | ★★★★★ | 0 | 0 |
| Rio Grande Rehabilitation And Healthcare Center | 22.6 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.