Vista Grande Rehabilitation And Healthcare Center
VISTA GRANDE REHABILITATION AND HEALTHCARE CENTER in CORTEZ, CO — inspection on March 6, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
she would not have been able to pick herself off the floor with a broken hip and put herself back to
The director of nursing (DON) was interviewed on 3/5/25 at 5:45 p.m.
The DON said LPN #1 notified
DON said the resident was diagnosed with fractures to both of her hips.
The DON said she did not know how the fractures occurred when it was reported to her.
LPN #1 was interviewed on 3/6/25 at 10:53 a.m. LPN #1 said Resident #1 was fine on the evening of 12/28/24.
She said the resident had no reports of pain and she walked normally down to her room.
She said the CNAs checked on her every two hours.
She said when the staff went to get her up to get dressed, she started crying in pain.
LPN #1 said she tried to get her up to see if she could bear weight but she could not stand.
She said she assessed Resident #1 with range of motion and hip palpitations (touch).
She said she was able to look at the resident's skin a little bit but did not see any concerns.
LPN #1 was interviewed on 3/6/25 again at 11:06 a.m.
She said she did not see a bruise on the resident's hip or leg but just remembered she saw a small lump on Resident #1's forehead about nickel-sized with some coloring to the skin.
She said she did not think the lump was new because new bruising was usually bright purple.
She said she did not document or report the lump on her forehead.
The DON was interviewed on 3/6/25 at 4:14 p.m.
The DON said unexplained injuries, such as what happened to Resident #1, should have been reported within 24 hours and it was not reported timely.
065153 03/06/2025
Vista Grande Rehabilitation and Healthcare Center 680 E Hospital Dr Cortez, CO 81321
was reported to her or documented.
The DON said she reviewed skin assessments prior to 12/29/24
get more details about the incident by asking more questions and making sure staff documented any
The DON said the resident had weak bones and the fractures could have happened before 12/29/24, according to a coroner report conducted in January 2025.
The NHA was interviewed a third time on 3/6/25 at 5:28 p.m.
She said a fall investigation was not done after Resident #1's 1/23/25 incident because the facility did not feel there was a fall.
She said a bruise of unknown origin was not investigated because the staff did not see the bruise and felt it did not happen at the facility.
She said she checked to see if the resident was on blood thinners but she was not.
She said she did not do a full abuse investigation because there was no indication of abuse.
The NHA said she never figured out why the resident had an oxygen saturation level of 55% because she did not have respiratory problems.
The NHA said she was not aware of Resident #1's lump on her forehead with slight coloring until the LPN #1 contacted her today (3/6/25).
She said she would have conducted a fall investigation to see what had happened if she would have known about the lump on the forehead earlier.
She said the lump could have been caused by a fall, however, she still felt Resident #1 did not fall.
She said nothing was documented about the lump on her head.
The NHA said a staff education regarding falls was conducted on 1/28/25 and 1/29/25, just in case Resident #1 injuries were a result of an undocumented fall that was not reported.
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Vista Grande Rehabilitation and Healthcare Center 680 E Hospital Dr Cortez, CO 81321
schedule for her, but she said Resident #2 was toileted every two hours, which was standard for any
and go to the bathroom by herself and not tell anyone.
She said the care planned intervention bowel and bladder program for Resident #2 after her 1/4/25 fall meant she would be toileted every two hours.
The DON said all residents were checked on every two hours.
According to the summary, Resident #1 was incontinent of bowel, which was unusual for her, and she was soaking wet with sweat.
The CNAs began to turn her on her side and she started to scream and scratch at them.
The resident was diaphoretic (sweating) and licensed practical nurse (LPN) #1 was notified. LPN #1 assessed the resident and she hollered out when her hips were palpated (touched).
The resident was hypoxic (low oxygen).
The staff finished cleaning her up and the paramedics were called to transport the resident to the hospital.
The summary identified the facility was notified that Resident #1 had right and left hip fractures.
The hospital contacted registered nurse (RN) #1 on 12/29/24 and notified the RN of a bruise/hematoma on her left proximal thigh.
The summary indicated the facility staff was asked about the bruise and none of the staff saw a bruise.
The skin assessments on 12/5/24, 12/12/24, 12/19/24 and 12/26/24 did not identify a bruise.
The 12/29/24 hospital #1 emergency department physician note documented Resident #1 was in significant pain and a computed tomography (CT) scan identified bilateral hip fractures and an orthopedic-surgeon was contacted.
The resident had a large left-sided proximal thigh hematoma with a suspicion of compartment syndrome (build up of pressure in the body).
According to the note, Resident #1 would be transferred to hospital #2 for higher level care.
065153
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065153 B.
Wing 03/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Grande Rehabilitation and Healthcare Center 680 E Hospital Dr Cortez, CO 81321
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.