Vista Grande Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Vista Grande Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 6, 2025

  Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents. Resident #2 admitted to the facility on [DATE] with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1's electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1's falls. […]

• Actual harm, isolatedF689May 9, 2024

  Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accidents/hazards as possible prevent falls for two residents (#3 and #58) of four residents reviewed for falls out of 41 sample residents. Resident #3, who had a history of falling, was admitted on [DATE] and readmitted on [DATE]. Resident #3's fall care plan, dated 4/5/23, documented the resident was to wear non-skid socks as a fall intervention. On 4/16/23 Resident #3 sustained an unwitnessed fall. There were no new fall interventions added to the resident's care plan until 6/16/23, when an intervention for a scheduled toileting program was implemented. […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2026

  Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service.Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24),4, retrieved on 6/9/26, Food employees shall clean their hands and exposed portions of their arms immediately as specified under S 2-301.12 before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms;… […]

• No harm, potential for more than minimal, patternF756Jun 3, 2026

  Based on record review and interviews, the facility failed to provide a rationale to act upon the pharmacist's recommendations in a timely manner for three (#2, #3 and #4) of five residents out of 36 sample residents. Specifically, the facility failed to provide a rationale for not acting upon the pharmacist's recommendations for Resident #2, Resident #3 and Resident #4. Findings include: I. Facility policy and procedure The Medication Regimen Reviews policy and procedure, revised February 2025, was provided by the nursing home administrator (NHA) on 6/3/26 at 7:17 p.m. It revealed in pertinent part, Upon receiving the medication recommendation report (MRR) from the pharmacist, the physician reviews and responds to the report. […]

• No harm, potential for more than minimal, patternF880Jun 3, 2026

  Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease.Specifically, the facility failed to:-Ensure nursing staff disinfected blood pressure cuffs and sit-to-stand mechanical lifts in between residents;-Ensure nursing staff performed appropriate hand hygiene in between assisting residents; and, -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents' rooms.Findings include:I. […]