Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Villa Grande Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was given warfarin twice daily instead of the prescribed once daily due to a failure to discontinue a previous order and inaccurate documentation of INR results. This led to the resident receiving excessive doses of the anticoagulant over several days, with staff not updating the MAR with current INR values or completing scheduled INR testing.
A resident with dementia, mobility issues, and a history of falls experienced three unwitnessed early morning falls within a week, two resulting in injuries, due to the facility's failure to provide adequate supervision, timely physical therapy evaluation, and effective fall prevention interventions. The facility did not identify a pattern in the falls or promptly address contributing factors such as high blood pressure and UTI, leading to repeated incidents and injury.
Several residents were prescribed and, in some cases, administered psychotropic medications such as antipsychotics and antianxiety drugs without proper documentation of clinical indications, targeted behaviors, or physician rationale. In multiple instances, PRN medications were continued beyond recommended timeframes without evidence of need, and behavior monitoring was not consistently documented, leading to inappropriate use of these medications.
The facility did not consistently serve food at safe and appetizing temperatures, with multiple residents reporting that meals were often lukewarm or unpalatable. Surveyors observed delays in tray delivery and found that hot foods were served below required temperatures and cold foods above required temperatures, resulting in poor food quality and dissatisfaction among residents.
Staff did not consistently perform hand hygiene when assisting residents with meals, including after touching potentially contaminated items, and did not use appropriate PPE or follow enhanced barrier precautions for residents with catheters or pressure ulcers. Staff interviews revealed gaps in knowledge and inconsistent access to hand hygiene supplies, and observations showed that required PPE was not available in rooms where it was needed.
A resident was allowed to self-administer a chewable tablet at bedside without a documented assessment or physician's order, contrary to facility policy. Nursing staff permitted the practice based on their judgment, but the required interdisciplinary assessment and care plan update were not completed or documented.
The facility did not provide or post the required State Survey Agency (SSA) contact information, including phone number, address, and email, in an accessible manner. During interviews, several residents reported not knowing how to contact the SSA, and a walk-through confirmed the absence of this information. The NHA acknowledged that the information was not posted.
Multiple incidents occurred where residents with severe cognitive impairments and behavioral histories engaged in physical altercations, including one resident throwing water at another, a resident being kicked after entering another's room, and a resident slapping another following verbal provocation. These events were witnessed by staff and substantiated, but care plans did not always reflect risk for abuse or update interventions after incidents.
A resident with limited mobility and multiple diagnoses was not consistently assisted to ambulate to the dining room as required by the walk-to-dine program, despite clear indications in the Kardex and a green symbol on the wheelchair. Staff routinely transported the resident by wheelchair, and interviews revealed confusion about program participation and inadequate communication following discharge from PT. The care plan was not updated to reflect the ambulation intervention.
A facility failed to keep its medication error rate below 5%, with two errors observed out of 26 opportunities. An RN administered an eye drop formulation instead of the prescribed gel and documented a Calcium Carbonate tablet as given even though a resident declined it and kept it at bedside for self-administration without proper assessment or physician order.
The facility failed to maintain sanitary conditions in the kitchen, with issues in food storage and handling. Observations included dented cans, moldy and undated produce, and improper hand hygiene during meal preparation. Staff interviews revealed a lack of routine checks for food freshness and labeling, contributing to the deficiencies.
The facility failed to manage fluid intake for a resident with chronic kidney disease, leading to fluid overload and hospitalization. Additionally, another resident with diabetes did not receive proper education on dietary adherence, and her care plan was not updated to reflect her refusals. Staff interviews revealed confusion about fluid restriction orders and a lack of communication regarding dietary non-adherence.
Significant Medication Error in Warfarin Administration and Monitoring
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension, kidney disease, diabetes, stroke, and left-sided paralysis was administered warfarin, a blood-thinning medication, twice daily instead of the prescribed once daily at bedtime. The resident was admitted from the hospital with orders for warfarin and regular INR (international normalized ratio) monitoring to manage stroke risk. The initial physician's order specified warfarin 1 mg in the morning, with daily INR monitoring for dose adjustments. After an INR result was communicated to the physician, a new verbal order was given for warfarin 1.5 mg to be administered once daily in the evening, along with instructions to document the most recent INR and schedule the next INR test. However, the verbal order did not include discontinuation of the previous morning dose, resulting in the resident receiving both the morning and evening doses of warfarin from August 28 to September 9. During this period, facility nurses failed to update the medication administration record (MAR) with the most recent INR result from August 26, instead repeatedly documenting an outdated hospital INR result from August 22. The scheduled INR test for August 29 was not completed, and the error in warfarin administration continued until a subsequent INR test on September 10 revealed an elevated level of 4.5. The facility's medication administration policy required medications to be given as prescribed and for staff to contact the prescriber if a dosage appeared inappropriate or excessive. The anticoagulation protocol also required the use of a warfarin flow sheet to track dosage and response. Despite these policies, the failure to discontinue the prior warfarin order, lack of accurate INR documentation, and omission of scheduled INR testing led to the resident receiving excessive doses of warfarin over a prolonged period.
Failure to Provide Adequate Supervision and Timely Interventions for Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and timely interventions to prevent accidents for a resident with a high risk of falls. The resident, who had diagnoses including dementia, a history of falls, gait abnormalities, weakness, and insomnia, was admitted with significant cognitive impairment and required partial to moderate assistance with activities of daily living. Despite a physician's recommendation for a physical therapy (PT) evaluation and a transition to a walker without wheels for safety, the resident continued to use a four-wheel walker, and the PT evaluation was not conducted until nearly two weeks later. Within a short period, the resident experienced three unwitnessed falls, all occurring in the early morning hours when she got out of bed independently. Two of these falls resulted in injuries, including facial bruising and a head laceration requiring hospital treatment and stitches. The facility did not identify a pattern in the timing or circumstances of the falls, nor did they implement targeted interventions to address the repeated early morning incidents. Additionally, the resident's medical records indicated that she developed high blood pressure and a urinary tract infection (UTI) during this period, both of which increased her risk for falls, but these factors were not promptly identified or addressed in the fall prevention plan. The facility's fall protocol required staff to investigate causes of falls within 24 hours and to monitor and adjust interventions as needed. However, the resident's care plan and post-fall investigations did not reflect timely or effective changes in response to the repeated incidents. The resident continued to use unsafe equipment, was not provided with recommended therapy services in a timely manner, and did not receive increased supervision or specific interventions during the high-risk early morning hours. Staff interviews confirmed gaps in communication, delayed implementation of interventions, and a lack of recognition of the fall pattern.
Failure to Justify and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications, including antipsychotics and antianxiety drugs, were only prescribed and administered when clinically justified and properly documented. Multiple residents were prescribed PRN (as needed) psychotropic medications without clear documentation of a diagnosed specific condition or indication for use, as required by facility policy. In several cases, there was no evidence in the medical records or progress notes that residents exhibited behaviors or symptoms warranting the use of these medications, and behavior monitoring was either not documented or not transcribed onto the appropriate records. For example, one resident with chronic kidney disease and bipolar disorder was prescribed PRN olanzapine and lorazepam for agitation and anxiety, but there was no documentation of any episodes of agitation, anxiety, or related behaviors prior to the prescription. Staff interviews confirmed that the resident had not displayed aggressive or anxious behaviors, and there was no place in the electronic medical record to document such behaviors if they occurred. Similarly, another resident with severe dementia and psychotic disturbance was continued on a high dose of olanzapine despite only one documented episode of verbal aggression and paranoid delusions over several months. The rationale for continuing the medication at a higher-than-recommended dose was based on a single poor interaction with family, without ongoing documentation of targeted behaviors. Additionally, two other residents were prescribed PRN antianxiety medications for extended periods beyond the 14-day limit without proper physician rationale or evidence of anxiety. In one case, the only rationale provided for extending a PRN diazepam order was the resident's hospice status, which was later discontinued without updating the medication order or rationale. In another case, a resident was prescribed PRN lorazepam for anxiety or shortness of breath, but neither the resident nor their family reported a history of anxiety, and there was no documentation of anxiety or use of the medication. The facility's failure to document clinical indications, monitor behaviors, and ensure appropriate prescribing practices led to the deficiency.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at appropriate temperatures, as required by its own policy. The policy specified that hot food should be held at 135 degrees Fahrenheit or above and cold food at 41 degrees or below until served. However, observations and interviews revealed that food was often served lukewarm or cold, and residents reported dissatisfaction with the taste and temperature of their meals. Multiple residents stated that hot food was not always warm, meat was dry and tasteless, and food sometimes did not taste good. Resident council minutes from two consecutive months also documented complaints about meals being lukewarm or not hot enough, especially for those receiving room tray service. Surveyors observed delays in meal tray delivery, with carts sitting in the hallway for several minutes before trays were distributed. During one observation, a meal cart sat for six minutes before delivery began, and in another, the cart door was left open while waiting for an alternate meal to be prepared, further compromising food temperature. A test tray evaluated by surveyors after all trays were delivered showed that all hot food items were served at temperatures well below the required 135 degrees Fahrenheit, and a cold dessert was served above the required 41 degrees, resulting in unpalatable food temperatures and poor food quality. Staff interviews confirmed awareness of the issues, with the dietary manager acknowledging resident complaints about food temperature and quality, and noting that delays in tray delivery contributed to the problem. The director of nursing stated that timely delivery of trays was necessary to maintain appropriate food temperatures. The registered dietitian also noted that food not served warm would not be as appetizing. These findings demonstrate a failure to ensure that food was consistently served at safe and appetizing temperatures, as required by facility policy.
Failure to Ensure Consistent Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently perform hand hygiene when providing meal assistance to residents. During a lunch meal observation, a CNA used alcohol-based hand rub (ABHR) before assisting residents but subsequently touched her nose, picked up a pen from the floor, and continued to assist residents without reapplying ABHR. The CNA also picked up an ABHR cap from the floor and then assisted a resident with her beverage without performing hand hygiene. Another CNA provided meal assistance to two residents without performing hand hygiene between assisting each resident. Both CNAs acknowledged in interviews that hand hygiene should be performed before and between assisting residents, but one CNA reported not having ABHR available due to supply shortages. The facility's infection prevention and control program policy requires staff to adhere to hand hygiene practices to prevent the spread of infections. However, observations revealed that staff did not consistently follow these practices, particularly during meal assistance. Staff interviews indicated gaps in knowledge and inconsistent access to hand hygiene supplies, with one CNA stating her ABHR was in her backpack and the supply cabinet was empty. The infection preventionist (IP) and director of nursing (DON) confirmed that hand hygiene training was provided at hire and during outbreaks, but could not specify when the last training occurred, and the clinical consultant could not find recent training records related to hand hygiene during meal assistance. Additionally, the facility failed to ensure the use of enhanced barrier precautions (EBP) and appropriate personal protective equipment (PPE) for residents with conditions such as urinary catheters and pressure ulcers. Multiple observations showed that rooms of residents requiring EBP lacked PPE supplies, and staff did not don PPE when providing direct care. Staff interviews revealed a lack of awareness regarding EBP requirements, with some staff believing only gloves were necessary for residents with catheters or pressure ulcers. The infection preventionist stated that residents with these conditions should be on EBP and that staff should use gloves and gowns, but this was not consistently implemented.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a proper assessment was conducted to determine if a resident was clinically appropriate to self-administer medications. According to facility policy, the interdisciplinary team is required to assess each resident's cognitive and physical abilities before allowing self-administration of medications, and this decision must be documented in the medical record and care plan. In the case reviewed, a resident over the age of 65 with diagnoses including GERD and osteoporosis, and who was cognitively intact but required moderate assistance with some activities of daily living, was observed to have a medication cup with a chewable tablet left at the bedside at her request. Nursing staff allowed the resident to keep the medication at her bedside and self-administer it, but there was no documentation of a formal assessment or a physician's order permitting self-administration. Interviews with nursing staff revealed that while some staff felt it was safe for the resident to self-administer the medication, they could not recall if a formal assessment had been completed. The DON confirmed that policy requires a self-administration assessment, physician notification, and care plan update, but acknowledged that no such assessment had been completed for this resident. Review of the electronic medical record confirmed the absence of documentation for a self-administration assessment or a physician's order for the resident to self-administer the medication.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to ensure that residents received notices both orally and in writing, including a written description of their legal rights, in a format and language they could understand. During a group interview with five interviewable residents, all stated they were unaware they could contact the State Survey Agency (SSA) and did not know where to find the SSA's contact information. Observations during a facility walk-through confirmed that the required SSA contact information, including phone number, address, and email address, was not posted in any accessible location. The nursing home administrator also confirmed that the necessary contact information was not posted within the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically physical abuse and altercations between residents, as evidenced by multiple incidents involving three residents with severe cognitive impairments and behavioral histories. In one incident, two residents with dementia and histories of agitation and aggression engaged in an altercation at a lunch table, where one resident threw water at the other. Both residents had documented behavioral care plans, but the care plan for the resident who was the victim did not indicate a risk for abuse or prior victimization. The incident was witnessed by a CNA, and both residents were subsequently monitored, but the event itself was substantiated as it occurred. Another incident involved a resident entering another resident's room and physically kicking her after being asked to leave. The assailant had a documented history of wandering, intrusiveness, and physical aggression, with care plan interventions focused on redirection and monitoring. However, after the physical altercation, the care plan did not reflect new interventions specific to the incident. The event was witnessed by a CNA, and the victim was checked for injury, but the documentation did not indicate a comprehensive assessment for injury at the time of the incident. A further altercation occurred when one resident verbally provoked another, resulting in the provoked resident slapping the other in the face. Both residents had severe cognitive impairments and behavioral symptoms, with care plans addressing their aggression and agitation. The incident was witnessed by both an RN and a CNA, and the residents were separated. The documentation confirmed that neither resident recalled the incident, but the physical contact was substantiated. These events demonstrate that the facility did not prevent or adequately address resident-to-resident physical abuse, as required by policy.
Failure to Provide Consistent Ambulation Services for Resident on Walk-to-Dine Program
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with limited range of motion consistently received appropriate restorative nursing services to maintain ambulation, as outlined in the facility's policy. The resident, who had diagnoses including functional quadriplegia, history of falls, altered mental status, and fibromyalgia, was dependent on staff for several activities of daily living and required moderate assistance with transfers and repositioning. Despite being identified for the walk-to-dine program, which was intended to help maintain mobility by assisting the resident to ambulate to the dining room, staff routinely transported the resident by wheelchair without offering ambulation assistance. Observations showed that staff did not offer to ambulate the resident to the dining room, instead wheeling her in a wheelchair. The resident reported that she was only assisted to walk to the dining room once in the past two weeks, despite a green card on her wheelchair indicating participation in the walk-to-dine program. The resident expressed concern about losing her ability to ambulate due to the lack of consistent participation in the program. The Kardex instructed staff to offer ambulation assistance for every meal, but the resident's care plan was not updated to reflect this intervention. Interviews with staff revealed confusion about the meaning of the green walking man symbol and uncertainty regarding which residents were on the walk-to-dine program. The director of rehabilitation confirmed that the program was intended to maintain residents' physical abilities and that staff should have been educated about the resident's participation. However, there was no clear documentation or communication in the electronic medical record to confirm that staff were informed about the resident's status in the program after discharge from physical therapy.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a calculated error rate of 7.69% based on two errors out of 26 observed opportunities. During medication administration, a registered nurse (RN) administered Genteal moisturizing eye drops instead of the Genteal moisturizing gel as ordered by the physician for a resident with dry eyes. The nurse did not clarify the discrepancy with the physician before administering the medication, despite the order specifying the gel formulation. Additionally, the same RN attempted to administer a scheduled dose of Calcium Carbonate chewable tablet to the resident, who declined to take it and requested to keep it at her bedside for later self-administration. The RN left the medication at the bedside and documented it as administered in the medication administration record (MAR), even though the resident had not taken it. The resident had not been assessed or authorized by a physician for self-administration of medications. Interviews with staff confirmed that the nurse should have clarified the medication order and should not have documented the medication as administered without witnessing its consumption.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner, as observed in the kitchen. Specifically, the facility did not ensure the safe and appropriate storage of food items in the refrigerators and pantry. Observations revealed a can of corn with a large and deep dent on the side, which was stocked on the can goods rack in the dry storage room. In the walk-in refrigerator, multiple containers of undated strawberries were found, with four containers containing moldy strawberries. Additionally, pre-bowled berries, a tub of lettuce, and a tub of cheese were not labeled or dated, and some of these items were served during the lunch meal service. The facility also failed to ensure that ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination. During the lunch meal service, a cook was observed touching her head and continuing to plate meals without performing hand hygiene. Another cook donned a glove without washing hands beforehand, handled meal tickets with the gloved hand, and then used the same glove to place hamburger patties on a skillet. These actions were contrary to the professional standards outlined in the Colorado Retail Food Establishment Regulations and the facility's own policies. Interviews with staff, including the dietary manager and cooks, revealed a lack of routine checks for produce freshness and proper labeling. The dietary manager acknowledged the risks associated with dented cans and moldy produce, emphasizing the need for proper labeling and dating of food items. The infection preventionist confirmed that hand hygiene training was provided, but the observed practices during the meal service indicated non-compliance with these standards.
Deficiencies in Fluid Management and Dietary Education
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for two residents. For one resident with chronic kidney disease and other health issues, the facility did not effectively monitor and manage fluid intake, leading to fluid overload and hospitalization. Despite a physician's order for a fluid restriction, the resident's fluid intake exceeded the prescribed limits on multiple occasions. The facility's documentation did not reflect any interventions to address the resident's significant weight gain, and the fluid restriction orders were misinterpreted as per shift rather than per day, resulting in excessive fluid intake. Another resident, who had type two diabetes and other health conditions, did not receive adequate education regarding the risks of not adhering to her diabetic diet. The resident frequently refused to comply with her dietary recommendations, and there was no documentation of education provided to her about the importance of diet adherence. The resident's care plan was not updated to reflect her refusals to follow the recommended diet, and the facility did not document any discussions with the resident about her dietary choices during care conferences. Interviews with staff revealed a lack of clarity and communication regarding dietary and fluid restriction orders. The registered dietitian was not informed of the resident's non-adherence to the diet, and there was confusion among staff about the interpretation of fluid restriction orders. The facility's policies on hydration and care planning were not effectively implemented, contributing to the deficiencies in care for the residents.
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What surveyors actually found near you
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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 Grand Junction
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Larchwood Health And Rehab Llc | 0.6 mi | — | 5 | 0 |
| Red Cliffs Post Acute | 0.6 mi | — | 1 | 0 |
| Eagle Ridge Post Acute | 1.5 mi | — | 4 | 1 |
| Mantey Heights Rehabilitation & Care Center | 1.6 mi | — | 2 | 0 |
| Center At Foresight Llc, The | 1.6 mi | — | 7 | 0 |
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