The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited March 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
VISTA GRANDE REHABILITATION AND HEALTHCARE CENTER
CORTEZ, CO · Medicare-certified · 101 beds
Needs attention
For-profitChain member
2 of 5 overall
Vista Grande Rehabilitation and Healthcare Center has a 2-star overall rating, with 1-star staffing and nurse staffing below the federal benchmark (2.96 vs. 4.1 hours per resident per day). It also has $36,023 in fines in the last 24 months and a recent federal penalty, while its quality measures are rated 5 stars.
Facility ratings
Health inspections
Staffing
2.956 hrs/resident/day
Quality measures
Last inspection: April 10, 2025Penalties, last 24 months: $36,023recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.956.
Staffing detail
- Registered nurses
- 0.37
- Licensed practical nurses
- 0.34
- Nurse aides
- 2.25
- Weekend nursing
- 2.47
Hours per resident per day.
Total staff turnover: 42%
Registered nurse turnover: 33%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
24.3%Steady
Residents with a fall causing major injury
3.8%Improving
Residents with pressure ulcers (bedsores)
2.4%Improving
Residents with a urinary tract infection
0%Steady
Residents who lost too much weight
0%Steady
Residents who were physically restrained
6.8%Worsening
Residents needing more help with daily activities
7.2%Improving
Residents whose ability to walk got worse
3.3%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
20.5%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
59%Improving
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
99.6%Worsening
Short-stay residents given the seasonal flu vaccine
98.2%Steady
Short-stay residents given the pneumonia vaccine
93.6%Worsening
What the inspectors found
The home failed to conduct and document a full facility assessment to ensure it had the resources needed for daily care and emergencies. Cited January 2020 — widespread issue, potential for harm.
View the original federal record
F-Tag 838 — 42 CFR §483.70 — S/S: F
The home failed to honor residents’ choices about treatment, research participation, and advance care instructions. Cited May 2024 — limited pattern, potential for harm.
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F-Tag 578 — 42 CFR §483.10 — S/S: E
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited May 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
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 May 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 947 — 42 CFR §483.95 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $20,111 was recorded.
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $15,912 was recorded.
- INSPECTION
Health inspection found 13 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 2 fines · $36,023 in total fines.
- $20,111
Federal fine
Mar 6, 2025
- $15,912
Federal fine
May 9, 2024
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of CENTENNIAL HEALTHCARE · 8 homes · 2.5 stars avg
- Occupancy
- 66.1 residents on an average day (65% of 101 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 46 years
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.