La Villa Grande Care Center
2501 Little Bookcliff Dr, Grand Junction, CO 81501 · Mesa County · 96 certified beds · avg 82 residents/day · certified since Mar 1, 1989
Part of chain: STELLAR SENIOR LIVING (7 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 18, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
▲ Actual harm, one-off · May 22, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 19, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 16, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 26, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 11, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 15, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 18, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 22, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 22, 2025 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 22, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 22, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 22, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| May 22, 2025 | D · Potential for harm, one-off | The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss. |
| May 22, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| May 22, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 22, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Oct 8, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 8, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Nov 16, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 16, 2023 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Nov 16, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Aug 11, 2022 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 11, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 11, 2022 | E · Potential for harm, repeated | The facility did not perform required COVID-19 testing on residents and staff. |
| Aug 11, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (16 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 4 | 1 | G ▲ |
| 2023 | 16 | 1 | G ▲ |
| 2024 | 2 | 0 | F |
| 2025 | 10 | 2 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
5 fines totaling $89,269, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| May 22, 2025 | Fine | $31,736 |
| Jan 2, 2024 | Fine | $4,545 |
| Dec 11, 2023 | Fine | $11,538 |
| Nov 16, 2023 | Fine | $32,981 |
| Nov 16, 2023 | Payment Denial | 10 days from Dec 16, 2023 |
| Sep 11, 2023 | Fine | $8,469 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.51 | 3.89 | 3.95 | bottom 37% in Colorado; bottom 37% in the U.S. |
| Registered Nurse hours | 0.86 | 0.86 | 0.69 | top 42% in Colorado; top 23% in the U.S. |
| Weekend total nurse staffing | 2.99 | 3.44 | 3.50 | bottom 28% in Colorado; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.57 | 0.61 | 0.48 | top 43% in Colorado; top 25% in the U.S. |
| Total nursing staff turnover (%) | 34.8 | 47.1 | 45.8 | top 19% in Colorado; top 24% in the U.S. |
| RN turnover (%) | 43.8 | 44.6 | 42.9 | top 47% in Colorado; bottom 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.24, RN 0.80, weekend 2.76. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Charles Schwab Investment Management, INC. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| D.e. Shaw & Co., L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| Diversified Healthcare Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| H/2 Special Opportunities IV L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| SNH Proj Lincoln TRS LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| SNH TRS Licensee Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| SNH TRS, INC. | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| Sptihs Properties Trust | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2024 |
| Abp Trust | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/22/2024 |
| Benton, Evrett | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2021 |
| Benton, Evrett | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2021 |
| Bilotto, Christopher | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Blackrock INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/22/2024 |
| Braendle, Tracy | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/02/2024 |
| Braendle, Tracy | Individual | ADP of the SNF | NOT APPLICABLE | 12/02/2024 |
| Brown, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2023 |
| Brown, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "How do you communicate important notices to residents who speak another language or have trouble seeing or hearing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Larchwood Health and Rehab LLC | 0.6 mi | Grand Junction, CO | ★★☆☆☆ | 2/5 | abuse |
| Red Cliffs Post Acute | 0.6 mi | Grand Junction, CO | ★★☆☆☆ | 2/5 | abuse |
| Eagle Ridge Post Acute | 1.5 mi | Grand Junction, CO | ★★☆☆☆ | 1/5 | |
| Mantey Heights Rehabilitation & Care Center | 1.6 mi | Grand Junction, CO | ★☆☆☆☆ | 1/5 | |
| Center at Foresight LLC, the | 1.6 mi | Grand Junction, CO | ★★★★★ | 5/5 | |
| Canyon View Care Center | 11.3 mi | Palisade, CO | ★★☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 065253.