Vista Grande Rehab: Broken Hips Unreported - CO
The incident happened on December 28, 2024. According to the inspection report, LPN #1 said Resident #1 had been fine the evening before. She walked normally to her room. Staff checked on her every two hours through the night. Nobody reported anything wrong.
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LPN #1 tried to get her to stand. She could not bear weight. The nurse assessed her range of motion, pressed on her hips, and looked at her skin. She said she did not see a bruise on the hip or leg. Then, during a second interview the following day, she remembered something else: a small, nickel-sized lump on the resident's forehead with some discoloration to the skin.
She said she did not think the lump was new because new bruising was usually bright purple.
She did not document the lump. She did not report it.
Resident #1 was sent to the hospital screaming in pain. She was diagnosed with fractures to both hips.
The director of nursing said LPN #1 had called to tell her the resident was sent to the hospital because she was screaming. The director of nursing said she did not know how the fractures occurred when it was reported to her. She later told inspectors that an unexplained injury like this one should have been reported within 24 hours. It was not reported timely.
What the inspection report does not answer is how a woman ends up with bilateral hip fractures and a lump on her forehead between a nighttime check and a morning dressing routine. LPN #1 acknowledged as much in a way she may not have intended. She told inspectors that Resident #1 would not have been able to pick herself off the floor with a broken hip and put herself back to bed.
That sentence is doing a great deal of work. If the resident could not have gotten herself up from the floor, then something happened to her, and nobody who worked the overnight shift has explained what that was.
The inspection, conducted March 6, 2025, classified the harm level as minimal or potential for actual harm, with few residents affected. That classification reflects regulatory categories, not a judgment about what it means to wake up unable to move, screaming, with fractures in both hips and a mark on your head that a nurse saw and chose not to mention.
Vista Grande Rehabilitation and Healthcare Center sits on East Hospital Drive in Cortez, a small city in the southwestern corner of Colorado. The facility's plan of correction was not included in the inspection documents reviewed for this report.
The lump on the forehead is the detail that stays. A nurse looked at it, formed an opinion about its age based on its color, and moved on. She did not write it in the chart. She did not tell the director of nursing. She did not mention it to inspectors until her second interview, more than a day after the fact.
By then, Resident #1 was already at the hospital, diagnosed with two broken hips, and the window for a timely unexplained-injury report had closed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vista Grande Rehabilitation and Healthcare Center from 2025-03-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 13, 2026 · Our methodology
VISTA GRANDE REHABILITATION AND HEALTHCARE CENTER in CORTEZ, CO was cited for violations during a health inspection on March 6, 2025.
The incident happened on December 28, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.