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 Inn
Registered name: VISTA GRANDE REHABILITATION AND HEALTHCARE CENTER
CORTEZ, CO · Medicare-certified · 101 beds
Needs attention
For-profitChain member
Data as of July 1, 2026
2 of 5 overall
Vista Grande Inn in Cortez, CO has a 2-star overall rating, with very low staffing (1 star) and nurse staffing below the federal benchmark (2.82 vs. 4.1 hours per resident per day). It also has a recent federal penalty and $20,111 in fines in the last 24 months, while its quality measures are rated 5 stars.
Facility ratings
Health inspections
Staffing
2.824 hrs/resident/day
Quality measures
Last inspection: April 10, 2025Penalties, last 24 months: $20,111recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.824.
Staffing detail
- Registered nurses
- 0.30
- Licensed practical nurses
- 0.34
- Nurse aides
- 2.18
- Weekend nursing
- 2.51
Hours per resident per day.
Total staff turnover: 40%
Registered nurse turnover: 20%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
26.1%22%Improving
Residents with a fall causing major injury
5%1.8%Improving
Residents with pressure ulcers (bedsores)
3.5%1.5%Improving
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
0%1.9%Worsening
Residents who were physically restrained
5%5.5%No change
Residents needing more help with daily activities
2%8%Worsening
Residents whose ability to walk got worse
—4.1%—
Long-stay residents on antianxiety or sleep medication
20.3%24.1%Worsening
Short-stay residents newly given an antipsychotic
0%0%No change
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
13.8%16.6%Worsening
Residents with depressive symptoms
58.2%57.4%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—98.2%—
Short-stay residents given the pneumonia vaccine
91.9%93.9%Improving
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.
View the original federal record
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
Recent ownership change · Sep 1, 2022
Now operated by Vista Grande Rehabilitation and Healthcare Center, previously Vista Grande Inn.
- Ownership
- For profit - Corporation
- Chain
- Part of CENTENNIAL HEALTHCARE · 8 homes · 2.4 stars avg
- Occupancy
- 66.2 residents on an average day (66% of 101 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 47 years
The most recent standard health inspection was more than two years ago.
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.