Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Ridge Care And Rehabilitation during CMS and state inspections, most recent first.
Food was not consistently served at an appetizing temperature or in an acceptable texture. Several residents reported that meals were cold and a dessert was hard and inedible, with one resident noting difficulty chewing and pain with hard foods. Surveyors observed uncovered meal items during lunch service, and a test tray showed bratwurst and potatoes were cold to the palate, while staff acknowledged the dessert should have been soft and moist but was hard.
Sanitary Food Handling and Kitchen Cleanliness Deficiencies: A cook handled ready-to-eat and prepared foods with bare hands and without hand hygiene between tasks, including touching meal tickets and then handling hamburger patties. Surveyors also observed dirty kitchen equipment and surfaces, including spots and splashes on the wall, grease on a stove, dried oil and lint around a steamer and stove, and splashes around a food prep table. The DS acknowledged the cleanliness issues and stated all kitchen areas needed to be clean.
Staff failed to follow infection control practices during medication passes, EBP care, and use of shared equipment. An LPN did not perform hand hygiene before or after resident medication administration, another LPN entered a resident’s room and gave insulin without hand hygiene, and an RN and LPN provided feeding tube care to a resident on EBP without wearing a gown. In addition, CNAs used a shared Hoyer lift for resident transfers and returned it to storage without cleaning it between uses.
A resident with Alzheimer's disease, anxiety, and depression received a PRN lorazepam order for agitation/anxiety without a stop date. The EMR lacked documentation of non-pharmacological interventions, a physician rationale for continuing the PRN psychotropic beyond the 14-day limit, and monitoring of behaviors or medication effectiveness, and there was no care plan addressing the medication.
Failure to Report and Assess a Resident Fall: A resident with a recent admission, anticoagulant use, and fall risk was reportedly dropped during a CNA transfer and injured her left hand and right shoulder. The fall was not reported to nursing staff at the time, and the resident was not assessed until the next day after the family reported the event. Facility policy required immediate reporting, assessment, and notification after any fall.
Failure to Monitor Prophylactic Antibiotic Use: The facility did not develop and implement an antibiotic stewardship system that tracked prophylactic antibiotic use or monitored effectiveness and adverse reactions. A resident with Alzheimer’s disease, stage 4 CKD, and severe cognitive impairment had long-term nitrofurantoin prophylaxis for UTIs with no stop date, later received cephalexin for a UTI, and the record lacked an antibiotic care plan or documentation of monitoring.
A resident with dementia and cognitive decline was not protected from sexual abuse by another resident, as staff failed to document critical details of the incident, did not update care plans or monitor behaviors, and did not confirm or document consent for an intimate relationship. The resident's representative was not informed of the incident or any relationship, and staff interviews revealed inconsistent understanding and documentation of monitoring and consent procedures.
Two residents at risk for skin breakdown did not consistently receive weekly skin assessments as ordered by physicians and facility policy. Review of electronic medical records showed multiple weeks where assessments were not documented, and staff interviews confirmed reliance on paper schedules rather than electronic alerts, leading to missed assessments.
A resident who was dependent on staff for ADLs and had complex medical needs did not receive scheduled showers as required by facility policy and her preferences. Over a 30-day period, documentation showed only two showers were provided, with no records of refusals or reasons for missed showers. Staff interviews revealed inconsistent assignment of shower duties and incomplete documentation, resulting in the resident not receiving necessary hygiene care.
A resident with multiple complex medical conditions did not have physician visit progress notes maintained in the EMR as required, due to the physician's revoked system access and changes in facility procedures for handling medical records. As a result, the resident's medical record was incomplete and not readily accessible to staff.
Food Served Cold and Dessert Served Hard
Penalty
Summary
Food and drink were not consistently served in a palatable, attractive, and safe appetizing temperature. During a resident group interview immediately after lunch, four interviewable residents said the dessert served was hard and could not be broken up or eaten, and several said their lunch was not served warm. One resident said the food in the main dining room was usually cold when served, another said the lemon bar was as hard as a rock, and another said the dessert was inedible because it was too hard to eat. A resident also stated she had difficulty chewing some of the food served and could not eat hard food because it hurt her teeth. Observations of lunch service showed the pretzel breadsticks, bratwurst, baby bakers, and braised sauerkraut were not covered with lids. A test tray evaluated after residents had been served showed the baby bakers were dry and 115 degrees Fahrenheit, the bratwurst was 113 degrees Fahrenheit, and both were cold to the palate; the braised sauerkraut was also cold to the palate. The dietary manager acknowledged the lemon bar should have had a soft texture and be moist, but it was hard and most residents did not consume it. The dietary supervisor stated the staff should have noticed the hard texture and that food should be served at an appetizing temperature.
Sanitary Food Handling and Kitchen Cleanliness Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. During a continuous observation of lunch meal service in the kitchen, a cook handled ready-to-eat and prepared foods without performing hand hygiene between tasks. The cook opened an open bag of frozen chicken fingers and used bare hands to place them into boiling oil, then later grabbed slices of bread and burger buns without gloves and placed them on a skillet. The cook also placed cooked bacon on buttered bread and used his hands to cut the bread into two parts without gloves. The same cook later washed his hands, donned a glove on one hand, and handled meal tickets with the gloved hand. He flipped through and separated the tickets, did not remove the glove or perform hand hygiene afterward, and then used that same gloved hand to place four premade hamburger patties onto a skillet. The dietary supervisor stated that kitchen staff and dietary aides had been trained on proper handling of ready-to-eat food and acknowledged that the cook should have worn gloves and ensured ready-to-eat food was not contaminated. The nursing home administrator stated she would provide education for all kitchen staff on food safety and ensure ready-to-eat foods were handled in a sanitary manner. The facility also failed to ensure kitchen equipment was clean. During an environmental tour of the kitchen, surveyors observed black and red spots around one stove, food particles and red watery splashes on the wall between the two stoves, grease on the outside of the north stove, dried oil mixed with lint around the steamer and stove surfaces and edges, and white splashes around the food preparation table. The dietary supervisor stated that some dirty areas were not being used during food preparation, but also stated that all areas of the kitchen needed to be clean. He reported that deep cleaning was done once a month and a weekly cleaning checklist was completed, and said staff had tried several times to clean the splashes on the wall without success.
Infection Control Failures During Medication Administration, EBP Care, and Shared Equipment Use
Penalty
Summary
The facility failed to maintain infection control practices during medication administration, enhanced barrier precautions (EBP), and shared equipment use. During observation, an LPN administered medications to one resident without performing hand hygiene after preparing the medications and before entering the room, and then failed to perform hand hygiene appropriately after glove use while giving eye drops. During a separate observation, another LPN prepared insulin for a different resident, removed gloves, entered the resident’s room without performing hand hygiene, and then donned gloves to administer the insulin without performing hand hygiene first. The facility also failed to follow EBP requirements for a resident with a feeding tube. An RN entered the resident’s room, put on gloves, and administered medication via the feeding tube without wearing a gown. On another observation, an LPN entered the same resident’s room, put on gloves, retrieved water, and flushed the feeding tube without wearing a gown. Staff interviews indicated the resident had signage at the door directing staff to wear a gown and gloves, and both the RN and LPN stated they were not aware a gown was required for the care provided. The facility further failed to clean shared resident-care equipment between uses. A CNA used a Hoyer lift to transfer one resident and returned it to storage without cleaning it. On another observation, a different CNA used the same Hoyer lift to transfer another resident and also did not clean it afterward. Staff interviews confirmed the lift was shared among multiple residents and was supposed to be cleaned after each use, but one CNA stated she did not clean it because cleaning wipes were not available where they were usually stored.
Unnecessary PRN Psychotropic Medication Use Without Required Documentation or Care Plan
Penalty
Summary
The facility failed to ensure that Resident #7 was free of unnecessary psychotropic medication use. Resident #7, who was over age 65 and had diagnoses of Alzheimer's disease, anxiety disorder, and depression, was assessed as having short- and long-term memory problems, severely impaired cognitive skills for daily decision-making, and dependence on staff for all activities of daily living. The September 2025 physician order included lorazepam 0.5 mg by mouth every four hours as needed for agitation/anxiety, ordered on 9/9/25, and the order did not include a stop date. Record review showed no documentation in the resident's comprehensive care plan related to the use of the antianxiety medication. The electronic medical record did not show documentation of non-pharmacological interventions attempted, a physician rationale for continuing the PRN lorazepam beyond 14 days, or monitoring of the resident's behaviors or the medication's effectiveness. Staff interviews confirmed that PRN psychotropic medications were limited to 14 days, that the resident should have been reassessed for continued use, and that a care plan should have been in place for monitoring side effects and effectiveness.
Failure to Report and Assess a Resident Fall
Penalty
Summary
The facility failed to ensure staff reported and assessed a fall for Resident #82 in accordance with the facility’s fall policy and professional standards of practice. The resident was a new admission, age greater than 65, with diagnoses including after care following joint replacement surgery, long term use of an anticoagulant, chronic pain, and depressive episodes. The resident’s admission assessment documented that she was alert and oriented and required moderate assistance with one staff member and a front wheel walker for transfers. According to the resident’s representative, on 9/21/25 the resident was being transferred by a CNA and was dropped. The representative stated the resident hurt her left hand and right shoulder when she fell, and that the nurse did not assess the resident after the fall. The facility’s fall policy stated that if a resident had a fall, or was found on the floor without a witness, nursing staff were to record vital signs, evaluate for possible injuries, complete an incident report, conduct a post-fall head-to-toe evaluation, and notify the physician, DON, and nursing supervisor. The record showed the fall was not reported until the daughter informed staff the next day. A nursing progress note documented that the daughter reported the fall and described the resident’s legs becoming weak during transfer back to bed, with the resident falling back into a recliner and hitting her left hand and right shoulder. A purple bruise was observed on the left hand, the right shoulder was assessed with no redness or bruising, and the physician was notified for x-rays. Staff interviews confirmed that a CNA should immediately report a fall to the nurse, the nurse should assess the resident before moving her, and the fall should be communicated to the physician, family, and DON; however, the DON stated she was not aware of the fall until it was reported at the start of the survey.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one resident. The facility’s antibiotic stewardship policy, revised in May 2025, stated that the purpose of the program was to monitor antibiotic use and educate staff on antibiotic stewardship, but it did not address prophylactic antibiotics. Staff interviews indicated the facility did not have a tracking and monitoring system in place for prophylactic antibiotic use. Resident #7 was an older adult with Alzheimer’s disease, stage 4 chronic kidney disease, severe impairment in cognitive skills for daily decision-making, and dependence on staff for all activities of daily living. The resident’s record showed an order for nitrofurantoin macrocrystal 50 mg at bedtime for UTIs as prophylaxis, ordered in April 2024 with no stop date, and a later order for cephalexin 500 mg four times daily for UTI for 10 days. The resident’s care plan did not include antibiotic medication, and the electronic medical record did not show documentation that the facility monitored the resident for adverse reactions or the effectiveness of the prophylactic antibiotic.
Failure to Protect Resident from Sexual Abuse and Inadequate Documentation of Consent
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, despite having policies in place prohibiting abuse, mistreatment, and neglect. On the date of the incident, a certified nurse aide observed one resident fondling another resident's private areas in a common area. The facility's investigation did not document critical details such as the specific areas touched, whether the touching was over or under clothing, or include signed witness statements from staff. The investigation also failed to clarify whether the relationship between the two residents was consensual, as there was confusion regarding the identity of the resident with whom the victim had a prior relationship. The resident who was the victim had diagnoses including multiple sclerosis, generalized muscle weakness, and unspecified dementia, with documented cognitive decline and dependence on staff for daily care. The resident's representative stated that the resident would not be able to understand or consent to intimate contact due to her dementia and was not aware of any relationship with the alleged perpetrator. The care plans and medical records for both residents did not contain updated interventions, documentation of behavior monitoring, or sexual consent assessments following the incident. There was also no evidence that the residents' representatives were properly informed or that the care plans were revised to address the incident. Staff interviews revealed inconsistent knowledge and documentation regarding monitoring for inappropriate touching and consent. Some staff believed monitoring was in place, but there was no supporting documentation in the medical records. The facility administrator acknowledged that there was no formal assessment tool for determining capacity to consent to sexual relationships, and the medical director indicated that consent should be obtained from representatives for residents with dementia. However, no such documentation was found, and the investigation relied on assumptions about the residents' relationship without confirming consent or informing the appropriate parties.
Failure to Consistently Complete and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin assessments were consistently completed for two residents, as required by physician orders and facility policy. For one resident with diagnoses including amyotrophic lateral sclerosis, subdural hemorrhage, malnutrition, and dysphagia, the care plan and physician orders specified weekly skin assessments to be documented every Sunday evening. However, review of the electronic medical record revealed that several weekly assessments were not documented during the review period, excluding the weeks the resident was hospitalized. The resident, who was cognitively intact but dependent on staff for mobility and care, was unable to confirm when her skin was last assessed. Another resident, with a history of atherosclerotic heart disease, chronic heart failure, fibromyalgia, muscle weakness, and dementia, also had a care plan and physician order for weekly skin assessments every Tuesday evening. The record review showed that multiple weekly assessments were missing during the review period. This resident was moderately cognitively impaired, required substantial assistance with mobility and hygiene, and was always incontinent of bowel and bladder, placing her at risk for skin breakdown. Staff interviews confirmed that weekly skin assessments were expected and that documentation should occur in the electronic medical record. However, it was noted that nurses appeared to rely on a paper schedule rather than electronic alerts, which may have contributed to missed assessments. Both the regional clinical consultant and nursing staff acknowledged the missing documentation for the two residents.
Failure to Provide Scheduled Showers and Maintain Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene, specifically by not providing showers according to the resident's preferences and the facility's own schedule. The resident, who had diagnoses including amyotrophic lateral sclerosis, subdural hemorrhage, protein-calorie malnutrition, and dysphagia, was cognitively intact and required staff assistance for toileting, dressing, bed mobility, and transfers. Observations over multiple days showed the resident with greasy, unwashed hair, and the resident communicated that she had not received a shower in about 10 days, expressing a preference for at least one shower every seven days. Review of documentation revealed significant gaps in shower provision and record-keeping. The facility's policy required documentation of showers, refusals, and any interventions, but records showed that the resident received only two showers over a 30-day period, despite being scheduled for two showers per week. There was no documentation of shower refusals or reasons for missed showers in the electronic medical record, and the shower schedule had not been updated to reflect the resident's preferences since before her admission. Interviews with staff indicated that the designated shower aide was frequently reassigned to floor duties, leaving CNAs responsible for showers, but documentation and communication about completed showers and refusals were inconsistent. Staff were aware of the importance of showers for hygiene and skin integrity, but the lack of updated schedules, incomplete documentation, and inconsistent assignment of shower duties led to the resident not receiving showers as scheduled or preferred.
Incomplete Physician Documentation in EMR
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by its own Charting and Documentation policy and accepted professional standards. Specifically, the physician's visit progress notes for the resident were not maintained in the electronic medical record (EMR) and were not readily accessible. The last physician's visit progress note in the EMR was from April 2024, despite the resident being seen by the physician on multiple occasions after that date. The physician's notes for these subsequent visits were not uploaded to the EMR, resulting in incomplete documentation. This deficiency occurred after the facility eliminated its medical records department and assigned the responsibility of scanning medical records into the EMR to the receptionist. Additionally, the physician's access to the EMR was revoked when he ceased to be the facility's medical director, even though he continued to serve as the resident's primary provider. The physician's EMR access was not reinstated until the time of the survey, which contributed to the lack of timely and complete documentation in the resident's medical record. The resident involved had multiple complex medical conditions, including multiple sclerosis, generalized muscle weakness, and dementia, and was dependent on staff for most activities of daily living.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pueblo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pueblo Heights Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 1 | 1 |
| University Park Care Center | 1.5 mi | ★★★★★ | 1 | 0 |
| High Plains Post Acute Llc | 2.5 mi | ★★★★★ | 6 | 0 |
| Center At Park West Llc, The | 3.6 mi | ★★★★★ | 6 | 0 |
| Rock Canyon Respiratory And Rehabilitation Center | 4 mi | ★★★★★ | 1 | 0 |
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