Cycle 1
Health 2024-05-09 · Fire 2024-05-09
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cortez, CO
Vista Grande Rehabilitation And Healthcare Center
2-star overall rating with 2-star inspections with $36,023 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
680 E Hospital Dr, Cortez, CO
(970) 564-1122
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Centennial Healthcare
Operator or chain grouping
Approved since
1979-07-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
0.70
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.58
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.49
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,099
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9994
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.04
Baseline 18.80% · Performance 17.71% · Measure score 8.04 · Achievement 8.04 · Improvement 5.68
Healthcare-associated infections
4.69
Baseline 6.28% · Performance 6.43% · Measure score 4.69 · Achievement 4.69 · Improvement 0
Total nurse turnover
5.09
Performance 42.86% · Measure score 5.09 · Achievement 5.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.60
Baseline 3.14 hours · Performance 3.25 hours · Measure score 0.60 · Achievement 0.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 6.19% · Lower 95% interval 6.49% |
| Discharge to community | 54.05% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 53.85% · Lower 95% interval 46.02% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 56.82% |
53.69%
3.1 pts better
|
Numerator 25 · Denominator 44 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 22 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.43% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 3.57% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 7.32% |
8.2%
0.9 pts worse
|
Numerator 6 · Denominator 82 |
| Staff flu vaccination coverage | 94.12% |
42%
52.1 pts better
|
Numerator 80 · Denominator 85 |
| Discharge function score | 56.82% |
56.45%
0.4 pts better
|
Numerator 25 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 29.63% |
25.2%
4.4 pts better
|
Numerator 8 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.4%
0.5 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 5.0% · Q4 5.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.7% |
7.4%
53.3 pts worse
|
11.4%
49.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.4% · Q2 70.7% · Q3 58.2% · Q4 59.3% · 4Q avg 60.7% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
11.2%
8.3 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 20.7% · Q3 20.3% · Q4 21.4% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.0% |
20.6%
5.4 pts worse
|
16.7%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 25.0% · Q3 26.5% · Q4 27.1% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 4.7% |
0.1%
4.6 pts worse
|
0.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 5.0% · Q4 10.7% · 4Q avg 4.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.2% |
15.2%
11 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
14.6%
9.2 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.8% · Q3 2.0% · Q4 7.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
22.4%
7.2 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 24.2% · Q3 13.8% · Q4 7.1% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
3.7%
1 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.7% · Q3 3.5% · Q4 1.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
76.4%
18.1 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 91.9% · Q4 87.3% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
12.8%
2 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
75.6%
22.6 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.5% |
20.3%
12.8 pts better
|
23.9%
16.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.5% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-23 · Fire 2020-01-23
5 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2018-11-01 · Fire 2018-11-01
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-22
D · Potential for more than minimal harm
2020-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-05
E · Potential for more than minimal harm
2018-11-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-12-11
D · Potential for more than minimal harm
2018-11-01
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2018-12-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-24
G · Actual harm
2025-03-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-31
G · Actual harm
2024-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-05-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-09
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-05-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-02
G · Actual harm
2020-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-02-12
F · Potential for more than minimal harm
2020-01-23
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2020-02-18
E · Potential for more than minimal harm
2020-01-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-01-31
D · Potential for more than minimal harm
2020-01-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-02-17
D · Potential for more than minimal harm
2020-01-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-02-14
Penalties and ownership
What sits behind the stars
$20,111
2025-03-06
Fine
Fine · fine $20,111
Fine
$15,912
2024-05-09
Fine
Fine · fine $15,912
Fine
Ownership
Centennial Iii Colorado Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Centennial I Tbd Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Centennial M Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Centennial Ms Trust I
5% Or Greater Indirect Ownership Interest · Organization
Emssah Non- Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Gottlieb, Refoel
5% Or Greater Indirect Ownership Interest · Individual
Gottlieb, Refoel
Operational/Managerial Control · Individual
Gotts Consulting Colorado LLC
Operational/Managerial Control · Organization
Lydic, Carla
Operational/Managerial Control · Individual
Singer, Meir
Corporate Officer · Individual
Turpen, Mark
Operational/Managerial Control · Individual
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#2
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#3
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