Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Rock Creek Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Protect Residents from Repeated Verbal Abuse: A resident with schizophrenia and another resident with severe cognitive impairment were repeatedly verbally abused by a resident with known aggressive behaviors in the dining room. The first resident became fearful, avoided the dining room, and had sleep and participation changes, while the second resident became tearful after being called names and mocked. Surveyors found the abusive resident’s care plan did not reflect the interventions tied to the repeated incidents, and the victims’ care plans did not document the abuse episodes.
Surveyors found unsanitary conditions in the kitchen, including food debris and grease buildup under the steam table and oven area, debris around the steam table wheels, and dirt buildup in the ice machine. They also observed food items left uncovered or unlabeled and multiple refrigerated items past their discard dates, while staff interviews showed inconsistent practices for cleaning, labeling, dating, and discarding food items.
Failure to Document and Implement Effective Abuse Investigation Corrective Actions: A resident repeatedly engaged in substantiated verbal abuse with two other residents in the dining room, including yelling, foul language, mocking, and threatening statements. Although the facility documented various interventions such as 15-minute checks, separation, escorting to meals, medication changes, and de-escalation education, the records did not show consistent documentation of staff education or other resident-specific corrective actions, and one later investigation lacked staff interviews. The same resident was involved in four substantiated verbal abuse incidents, but the investigations did not show effective corrective actions to prevent recurrence.
Failure to Monitor and Report TD Symptoms: A resident receiving antipsychotic medications was observed with repeated lip smacking and other involuntary movements consistent with TD. Nursing staff documented the symptoms multiple times, and an AIMS assessment showed prominent facial, oral, and lower extremity movements with mild distress, but the physician was not notified and there was no record of recent psych/behavioral health follow-up related to the symptoms.
Failure to provide written bed-hold notice at hospital transfer: A resident with COPD, asthma, URI, and RSV was sent to the hospital for low O2 sat, cough, SOB, and respiratory distress, but the EMR had no documentation that she or her RP received the required bed-hold notice. RN said she did not know a bed-hold form was needed, and the SSD said she did not complete the form or notify the facility’s frequent visitor.
A resident with COPD, continuous O2 use, and moderate cognitive impairment had a nebulizer machine and mask left on a TV stand with visible brown residue and grease inside the mask. The chart had an order for albuterol neb treatments, but no orders or care plan interventions for cleaning, sanitizing, or storing the neb equipment, and staff interviews confirmed the mask should have been cleaned or replaced after use.
A resident with dementia, Parkinson's disease, sciatica, and a history of spinal fractures had an incomplete pain assessment and care plan that did not identify pain goals or acceptable pain level. Staff observed behaviors suggesting discomfort, but pain location was not consistently documented when PRN tramadol or acetaminophen was given, and the record did not show completed documentation of non-pharmacological interventions or their effectiveness.
Failure to address depression and psychosocial needs: A resident with dementia, depressive disorder, and behavioral issues had PHQ-9 scores showing mild to moderate depression, but the record did not document follow-up for the increased score or consistent implementation of behavioral health recommendations. The resident often isolated in his room, declined activities, and had care plan interventions for depression and verbal aggression that were not consistently reflected in the chart or carried out as documented.
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 Protect Residents from Repeated Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse by another resident, and survey findings showed repeated incidents in the dining room involving the same resident who had a known history of verbally aggressive behavior and threatening gestures. One resident, who was cognitively intact and had diagnoses including schizophrenia and depressive episodes, was verbally abused during a dining room altercation when the other resident yelled foul language, made threatening comments, and moved aggressively toward him. The resident later reported feeling fearful, nervous, upset, and uncomfortable around the other resident, with sleep disturbance, avoidance of the dining room, and reduced participation in meals and activities. He also stated staff did not talk with him about his concerns after the incidents. The record showed the facility investigated the first altercation and documented that both residents were placed on 15-minute checks, with staff education on de-escalation techniques. Despite those measures, a second verbal altercation occurred in the dining room when the same resident again approached the first resident, used insulting language, and threatened him. The investigation documented that the resident was already on 15-minute checks before the second incident, and the care plan for the resident with behavioral issues did not identify the interventions that had been implemented after the first event. Survey interviews also showed the resident was not consistently escorted to and from the dining room as intended. A second resident, who had severe cognitive impairment, limited verbal ability, and a history of vulnerability and trauma, was also verbally abused by the same resident in the dining room on two separate occasions. During one incident, the resident was called names and became tearful; during the other, the resident was mocked and again became tearful when interviewed. The record showed the resident’s care plans identified her as vulnerable and at risk for abuse, but they did not include the episodes of verbal aggression or the interventions used after those incidents. The survey also found no staff interviews documented for these events and no social services documentation related to the two verbal abuse incidents involving the two residents.
Kitchen Sanitation and Food Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. During the initial kitchen tour, surveyors observed food debris and grease buildup on the floor beneath the steam table and oven area, three unopened butter cups stored underneath the steam table, and dark brown residue, unidentified debris buildup, and dirt accumulation underneath the steam table and near the wheels. Staff interviews showed that dietary staff were expected to sweep and mop the kitchen after meals and at night, but the observed conditions remained present during the survey. The ice machine was also not maintained in a sanitary condition. Surveyors observed gray dirt and debris buildup on the upper interior portion of the ice dispensing opening and on the interior surface near the top of the door. A later observation identified the same concerns. Staff stated that dietary staff cleaned the ice machine weekly and that it was sanitized monthly, but the observed buildup remained in place. The food service supervisor acknowledged that the ice machine did not appear to have been cleaned the prior week because gray lint buildup was present on the interior surfaces. Food items were found improperly covered, labeled, dated, and discarded. A tray of banana pudding cake portions was observed in the walk-in refrigerator without a protective covering, wrapping, or label. In the dining room refrigerator, multiple food items and drinks were beyond their use-by or discard dates, including thickened cranberry cocktail, cranberry juice, orange juice, cantaloupe, Jello, butterscotch pudding, and an unlabeled pitcher of beverage. Staff also observed a resident’s pitcher being filled with cranberry beverage and returned to the refrigerator, then later placed on the meal tray cart for delivery. Staff interviews confirmed that some items were not wrapped or dated, that dates were not always clear as preparation dates or use-by dates, and that expired items were discarded only after being identified during the survey.
Failure to Document and Implement Effective Abuse Investigation Corrective Actions
Penalty
Summary
The facility failed to take appropriate corrective actions after four substantiated resident-to-resident verbal abuse incidents involving one resident and two other residents. The abuse investigations documented repeated verbal altercations in the dining room, including yelling, foul language, mocking, and threatening statements. In the first incident, two residents were separated after a verbal altercation, and the investigation substantiated verbal abuse. In the second incident, the same resident again engaged in a verbal altercation with the first resident, and the investigation again substantiated verbal abuse. In the third incident, the resident verbally abused another resident in the dining room, causing that resident to cry, and the facility substantiated the allegation. A fourth verbal altercation occurred later between the same two residents, and the facility again substantiated verbal abuse. The investigations documented interventions such as 15-minute checks, separating residents, escorting the resident to and from meals, medication adjustments, and staff education regarding de-escalation techniques. However, the record did not contain documentation of the staff education that was identified as a corrective action after the first incident. The second investigation repeated interventions that had already been in place before the incident, showing that the earlier measures had not prevented recurrence. The third investigation also listed interventions that had already been used previously, and the record did not show documentation that behavioral health services were offered until more than 30 days later. The investigation also failed to document staff education for the additional dining room observation and private dining room meal interventions, and the electronic medical record did not show that meals were offered in the private dining room. The fourth investigation did not include staff interviews and again substantiated verbal abuse. The facility identified four incidents involving the same resident, but the investigations did not show appropriate corrective actions to prevent further incidents. Interviews with the LPN, interim DON, and NHA indicated that abuse investigations should include documentation of interviews, statements, and resident-specific interventions in the care plan and communication tools, but the reviewed investigations did not consistently contain that documentation. The interim DON and NHA both stated that the investigations were not thorough and that the care plans for the involved residents could use improvement to reflect the interventions put into place after the altercations.
Failure to Monitor and Report Tardive Dyskinesia Symptoms
Penalty
Summary
The facility failed to ensure one resident receiving antipsychotic medication was monitored appropriately for signs and symptoms of tardive dyskinesia. Resident #7 had diagnoses including bipolar disorder, mild cognitive impairment, type 1 diabetes mellitus with ketoacidosis, and hypertension, and the March 2026 MDS showed he was cognitively intact with a BIMS score of 15 out of 15. He was receiving psychotropic medications, including Depakote ER and Seroquel, and also had a PRN order for Haldol for agitation related to bipolar mania. During interview, the resident was observed smacking his lips and stated he had noticed the lip smacking for the past couple of months. He said it was annoying and that the facility had not told him what they were doing to help him stop the lip smacking. The care plan included monitoring for side effects of quetiapine and periodically completing AIMS evaluations, and the April 2026 AIMS assessment documented a score of 13 with moderate facial and oral movements, including lip smacking, jaw movements, mouth opening, tongue movements, and lower leg movements, with mild distress noted. Record review showed nursing staff documented lip smacking on multiple occasions, including 3/11/26, 3/17/26, 3/26/26, 4/15/26, 5/4/26, and 5/18/26, but the resident's physician was not notified that he was exhibiting symptoms of tardive dyskinesia. The record also did not show that he had been seen by a psychiatrist or behavioral health consultant related to his diagnosis or tardive dyskinesia since 3/18/26. Staff interviews indicated nurses were expected to document side effects and notify the physician, but this was not done for the repeated lip smacking observations.
Failure to Provide Written Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide and document sufficient discharge preparation for one resident reviewed for a safe and orderly discharge. Specifically, the facility did not ensure that a written bed-hold notice was provided to Resident #22 and/or her representative at the time of transfer to the hospital. The facility’s Bed-Holds and Returns policy stated that residents or their representatives are to be given written information about bed-hold policies at the time of transfer, or within 24 hours if the transfer is an emergency, and that the notice explains the bed-hold duration, payment requirements, facility bed-hold policy, and return policy. Resident #22 was greater than 65 years old and had diagnoses including COPD, mild intermittent asthma, acute upper respiratory infection, and RSV. Her MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15, no impairment of upper or lower extremities, wheelchair use for mobility, and partial to moderate staff assistance with ADLs. She was transferred to the hospital for low oxygen saturation, cough, shortness of breath, and respiratory distress. Review of the EMR showed no documentation that Resident #22, who was her own responsible party, was provided a written bed-hold notice at the time of transfer. RN #1 stated she did not know a bed-hold form had to be completed before transfer, and the SSD stated she did not complete a bed-hold form with the resident when she was transferred and did not notify the facility’s frequent visitor of the transfer.
Nebulizer Equipment Left Dirty and Improperly Stored
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed. Resident #10 was admitted with chronic obstructive pulmonary disease, dependence on supplemental oxygen, and hypertension, and the 3/3/26 MDS showed moderate cognitive impairment with a BIMS score of 11 and continuous oxygen therapy. The resident had an order for albuterol sulfate nebulization solution, but there were no physician's orders for cleaning, sanitizing, or storing the nebulizer equipment, and the respiratory care plan did not include interventions related to cleaning, sanitizing, or storing the nebulizer machine or mask. During observations, Resident #10's nebulizer machine was found on the television stand in the room, and the nebulizer mask had visible brown residue buildup inside it and was greasy. The equipment remained in the room uncleaned on the following day, and the resident said he did not know how often staff cleaned the nebulizer mask or whether staff cleaned the equipment after use. Staff interviews indicated nurses were responsible for rinsing, sanitizing, and ensuring the nebulizer equipment remained clean and sanitary after each use, and the NHA stated respiratory equipment with visible buildup should be replaced; however, the resident's mask had not been cleaned or replaced when observed.
Incomplete pain assessment and inconsistent documentation of pain location and treatment
Penalty
Summary
The facility failed to provide effective pain management for one resident with Parkinson's disease, Lewy body neurocognitive disorder with dementia and behavioral disturbances, anxiety, depression, lumbar radiculopathy and sciatica, tremors, encephalopathy, and a history of lumbar compression fracture. The resident's pain care plan identified potential acute and chronic pain, restlessness, and fall risk, but it did not identify the resident's goal for pain management or acceptable level of pain. The resident's pain assessments also did not fully document pain history, prior treatments, non-pharmacological interventions, or all pain locations, including leg pain when present. Observations showed the resident biting clothing, biting lips, leaning forward to hold toes, and appearing uncomfortable while in bed and in a wheelchair. Staff noted the resident was hard to understand and believed the behaviors may have reflected pain, but the resident's pain location was not consistently identified during these episodes. The resident's records showed orders for fentanyl patch, gabapentin for painful legs, scheduled acetaminophen, PRN acetaminophen, PRN acetaminophen suppositories, Sombra gel, and PRN tramadol, along with orders to document pain twice daily and offer non-pharmacological interventions before pain medication. The record did not show documentation of which non-pharmacological interventions were attempted or whether they were effective. The medication administration record showed multiple administrations of PRN tramadol and PRN acetaminophen, but there was no documentation of the resident's pain location when those medications were given. Pain assessments completed in January and April 2026 were incomplete, with missing sections for acceptable pain level, non-pharmacological interventions, and some pain locations. Staff interviews confirmed that pain assessment should include pain history, impact on life, acceptable pain level, location, interventions, and effectiveness, and that the resident's pain location should be documented on the MAR and in progress notes.
Failure to Address Depression and Psychosocial Needs
Penalty
Summary
The facility failed to ensure a resident with diagnoses including dementia with behavioral disturbance and depressive disorder received appropriate treatment and services to support mental and psychosocial well-being. The resident’s MDS showed moderate cognitive impairment, verbal behaviors toward others, and depression identified through PHQ-9 screening. The resident also received an antidepressant and an antipsychotic medication, and the record showed no gradual dose reduction attempt or documentation that it was clinically contraindicated. Record review and observations showed the resident spent much of the day in his room with the lights off and blinds closed, often sat alone in the dining room, and told staff he did not like to participate in facility activities. The care plan identified depression, self-isolation, verbal aggression, and the need for psychosocial monitoring, emotional support, activities of interest, and behavioral interventions such as calm approach, positive reassurance, one-on-one interactions, and a quiet environment. A psychiatry note also recommended a more proactive approach to encouraging the resident to attend activities, such as telling him it was time to go rather than asking if he wanted to go, but this recommendation was not reflected in the electronic record. The resident’s PHQ-9 scores showed mild depression in September 2025, then moderate depression in December 2025 and again in March 2026, but the record did not show documentation addressing the increased score, follow-up, interventions, or services offered. Physician orders included monitoring for behaviors, isolation, side effects of psychotropic medications, and offering non-pharmacological interventions, but the record showed these interventions were not consistently implemented or documented as effective. Staff interviews confirmed the resident could become upset when approached in a way that suggested he was blamed for resident-to-resident altercations, and the administrator and social services director acknowledged they could not locate documentation showing why the PHQ-9 score increased or that the behavioral health recommendation had been incorporated into the care plan.
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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How nearby facilities compare on the same public inspection record.
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| 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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