GRAND VILLA ASSISTED LIVING

A recertification survey was completed on 12/10/25. Deficiencies were cited.

Based on records review and interviews, the facility (residence) failed to establish and maintain written plans to address emergencies affecting 54 current members (residents). Findings include: On 12/9/25 at 7:57 a.m., the emergency preparedness resident roster, to include names, room numbers, emergency contact information, and a facility diagram, as well as emergency policies and procedures (EPPs), was requested from the administrator via electronic communication. On 12/9/25 at approximately 9:35 a.m., the administrator provided a list of current residents that did not include the room numbers. On 12/9/25 at approximately 12:00 p.m., the administrator provided the EPPs. Review revealed that the documents described the unique risks and circumstances of a sister residence. On 12/9/25 at 9:30 a.m., Staff #6 stated that the administrator or assistant administrator would have the resident roster. On 12/10/25 at 12:30 p.m., the administrator agreed that the roster she provided did not include resident room numbers. She explained that the roster provided is simply a report from the electronic health record that can include the room number and is accessible to all staff. She acknowledged that staff were unable to access and stated that she would provide training. The administrator agreed the EPPs belonged to a sister residence. She stated they were aware of the issue and were working on updating the documents to meet regulatory requirements.

Based on records review and interviews, the facility (residence) failed to maintain a training program that trained staff on the health, safety, and services and supports to be provided related to the specific needs of members (residents) served, affecting 54 current residents. Findings include:1. Residence PolicyThe residence ' s undated First Aid and Cardiopulmonary Resuscitation (CPR) policy read in part: The residence is committed to ensuring the safety and well-being of all residents by maintaining compliance with Regulations 8.5-8.11, which requires at least one certified staff member be available at all times to provide First Aid and CPR. At least one staff member (must be) onsite at all times (and) must have (a) current adult first aid certification from a nationally recognized organization (e.g., American Red Cross, American Heart Association, National Safety Council or American Safety and Health Institute). 2. Record ReviewReview of Staff #8's personnel file, revealed a hire date of 1/5/23 The personnel file revealed Staff #8's first aid certification was issued on 8/7/24 by an organization that was not nationally recognized. Review of Staff #9's personnel file, revealed a hire date of 12/6/22. The personnel file revealed Staff #9's first aid certification was issued on 4/23/24, by an organization that was not nationally recognized. Review of the schedule for Staff #8 and Staff #9 revealed they typically work the 2:00 p.m. to 10:00 p.m. shiftReview of the staff schedules from 11/23/25 through 12/9/25, revealed that from 2:00 p.m. to 10:00 p.m., no staff on duty were first aid certified as required by 6 CCR 1011-1 Chapter 7, Part 8, Section 8.6, on the following dates: 11/23, 11/24, 11/30, 12/1 and 12/7-12/9/25.3. InterviewsOn 12/10/25 at 12:30 p.m., the administrator stated she was aware of the requirement for at least one first aid certified staff member to be made available at all times. The administrator also stated she was unaware that Staff #8 and Staff #9's first aid certifications were not from a nationally recognized organization. On 12/10/25 at 12:30 p.m., the assistant administrator, who is responsible for ensuring staff training, stated she was aware of the requirement for at least one first aid certified staff member to be made available at all times. The assisted administrator also stated she was unaware that Staff #8 and Staff #9's first aid certifications were not from a nationally recognized organization.

Based on records review and interviews, the facility (residence) failed to comply with authorized practitioner orders, affecting five of seven sample members (residents) (#1, #2, #3, #6, #7). Findings Include:1. Record ReviewResident #7 was admitted to the residence on 10/18/24, with a diagnosis including pulmonary embolism. Resident #7 ' s most recent care plan, dated 8/27/25, read in part, "resident requires licensed staff assistance with handling changes to prescription and/or communicating with pharmacy and prescriber."A practitioner's order, dated 8/25/25, directed the residence to administer Eliquis 5 mg twice daily. Review of Resident #7 ' s September, October, November and December 2025 Medication Administration Records (MARS), revealed the residence failed to administer Eliquis 5 mg as prescribed, for both doses on 9/27-9/30, 10/1-10/14, 11/1-11/4, and 12/8/25, because this medication was not available. On 10/14/25 the residence faxed an order to Resident #7 ' s practitioner that read (Resident #7) has not had her Eliquis 5 mg since 9/27/25. The practitioner wrote a new order on 10/14/25 that read in part: "Please give samples (of) Eliquis 5 mg twice a day." 2. InterviewsOn 12/9/25 at approximately 4:00 p.m., Resident #7 stated she was aware that she had not received her Eliquis. On 12/10/25 at approximately 4:30 p.m. the administrator and assistant administrator acknowledged it was their responsibility to ensure resident medications were administered as ordered, and stated Resident #7 ' s practitioner was contacted when her Eliquis could not be obtained from the pharmacy and was provided with a temporary supply. When the samples ran out, it was noted that Resident #7 ' s daughter obtained Eliquis and delivered it to the facility. The administrator acknowledged they would expect compliance with the regulation. She further stated if a resident runs out of their prescribed medication in the future, they will contact the practitioner as soon as possible to alert them that the resident is out of their prescribed medication they will request an order to discontinue it until the medication is refilled. Similar deficient practice was identified for Residents #1, #2, #3 and #6.

Based on records review and interviews, the facility (residence) failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting two of seven sample residents (#1 and #4). Findings Include:1. Resident #1 was admitted to the residence on 3/21/25 with a diagnosis of diabetes. A progress note, dated 10/15/25 at 3:15 p.m., read in part: Resident #1 had an altercation with another resident. During the altercation, the other resident, who was in a wheelchair, turned around after Resident #1 hit the resident in the head. The other resident hit Resident #1's leg with the wheelchair and caused Resident #1 to fall. He refused EMS and any care at the time. The most recent care plan update, dated 11/4/25, read in part: Resident #1 required staff awareness and support when care was declined or resisted, including verbal refusal, pulling away, or nonverbal signs of distress during care tasks. Staff were directed to use a calm tone and familiar staff when possible. If care was repeatedly refused, staff were directed to notify the supervisor and document. Re-approach later unless refusal presents an immediate health or safety concern. The care plan further read staff to provide skin and nail care. However, the care plan did not include specific interventions for refusals, how often staff were to monitor skin and nail health, or indicate any interventions or direction to staff regarding Resident #1's diabetes diagnosis or how to effectively care for those needs. A review of the task administration record (TAR) for November 2025 for Resident #1 revealed that he refused "monitoring and providing cues when needed to assist with dressing and undressing" on 11/1, 11/2, and 11/29 in the morning; and 11/3, 11/4, 11/18, 11/19, 11/23, and 11/26/25 in the evening. No documentation was provided under the section "Resistance to care, provide supervision and monitoring to help prevent/redirect resistance to accepting care." Additionally, no task was assigned for assistance with skin monitoring & nail care. A review of progress notes from 10/15/25 to 12/9/25 revealed no evidence of documentation of any refusal of care from Resident #1. A progress note, dated 12/2/25 at 1:30 p.m., read in part: Resident #1 reported to the activity director toe pain. Resident #1 had a swollen, red, and odorous second toe on the left foot. Resident #1 stated that he was not aware of how this happened. Resident #1 was scheduled for an appointment with the practitioner's office at 1:40 p.m. that day. A progress note, dated 12/2/25 at 5:45 p.m., read in part: Resident #1 was sent to the emergency department (ED) by the practitioner. At approximately 5:15 p.m., residence staff received an update from the ED: "Resident #1 is being admitted to the hospital. Resident #1 had started on antibiotics and was getting an MRI done. Resident #1 may possibly need surgery, but they won't know until after they see the MRI. Resident #1 was also really close to being septic if he wasn't already."A progress note, dated 12/5/25 at 3:15 p.m., read in part: The case manager from the hospital provided an update on Resident #1: "Resident #1 has osteomyelitis in both feet and has had all of his toes removed. He is not participating in PT and OT at the hospital. Resident #1 is not to be up and ambulating, and Resident #1 is up and walking and causing his wounds to bleed."2. InterviewsOn 12/9/25 at 3:50 p.m., the administrator stated that Resident #1 alerted the activity director of toe pain, and was taken to urgent care. Once he got to the appointment, he was taken to the ED and then admitted into the hospital. The administrator agreed that there were inadequate interventions in place surrounding the resident's resistance to care, preventing adequate monitoring of his skin health. On 12/9/25 at 4:00 p.m., the assistant administrator stated when she attempted to monitor Resident #1 while in the shower on the Saturday before he was admittedto the hospital, he refused to allow her into the shower room. She stated that Resident #1 regularly saw his practitioner, but not for podiatry care, and she admitted that no other professionals were considered to help support his podiatry care. On 12/10/25 at 12:30 p.m., the administrator agreed the infection in Resident #1's toe is likely related to his diabetes diagnosis. She agreed that proper monitoring of podiatry needs is especially important with this diagnosis. She agreed that the care plan was not updated to include monitoring of skin and nail care, diabetes and approach to manage resistance to care. She stated that the resistance to care from Resident #1 made it very difficult to monitor his skin health, but acknowledged that more could have been done. On 12/10/25 at 12:30 p.m., the assistant administrator stated that Resident #1's resistance to care made it difficult to properly monitor his skin health. She explained that they attempted to try different staff members to improve cooperation; however, she acknowledged that more should have been done. She agreed that the care plan failed to have updated and effective interventions for resistance to care. 3. Similar deficient practice was found for Resident #4.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised that it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 Section 8.7000.8.7001. B Individual Rights under the Home and Community-Based Services (HCBS) Settings Final Rule 2. Basic Criteria Applicable to All HCBS Settings(a) All HCBS Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001. B.4:(iii) The setting ensures an individual's rights of privacy, dignity, and respect, and freedom from coercion and Restraint.(2) The right of privacy includes the right not to have one's name or other confidential items of information posted in common areas of the setting. 8.7001. B Individual Rights under the Home and Community-Based Services (HCBS) Settings Final Rule 3. Additional Criteria for HCBS Settings(a) Provider-Owned or -Controlled Residential Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001. B.4:(iii) The Residential Setting does not have institutional features not found in a typical home, such as staff uniforms; entryways containing staff postings or messages; or labels on drawers, cupboards, or bedrooms for staff convenience. 8.7001. B Individual Rights under the Home and Community-Based Services (HCBS) Settings Final Rule 3. Additional Criteria for HCBS Settings(a) Provider-Owned or -Controlled Residential Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001. B.4:(v) Individuals have access to food at all times, choose when and what to eat, have input in menu planning (if the setting provides food), have access to food preparation and storage areas, can store and eat food in their room/unit, and have access to a dining area for meals/snacks with comfortable seating where they can choose their own seat, choose their company (or lack thereof), and choose to converse (or not);8.7001. C Additional Provisions Regarding Rights and Responsibilities of Members and Other Individuals 1. Member and Other Individual Rights(c) No individual, their Family Members, Guardians, or other Legally Authorized Representatives may be retaliated against in their receipt of Case Management services or supports or direct services and supports as a result of attempts to advocate on their own behalf.(e) The individual and the individual ' s Legally Authorized Representative as necessary is fully informed of the individual ' s rights and responsibilities.(h) The individual and/or the individual ' s Legally Authorized Representative has access to a uniform Complaint system provided for all individuals served by the Case Management Agency.(p) Members and other individuals have the right to know in advance if services are going to be stopped. 8.7412 Environmental Standards for Provider-Owned or -Controlled Settings(A) Provider Agencies shall ensure that Provider-Owned or -Controlled Settings defined at Section 8.7001. A.13 and .14 shall comply with all the environmental standards outlined below, in addition to the requirements set forth in Section 8.7001. B(1) The Provider Agency shall conduct fire drills at least quarterly at each physical facility.

A relicensure survey was completed on 12/10/25. Deficiencies were cited. A change of ownership occurred on 6/5/24.

Based on record review and interviews, the residence failed to have at least one staff member with current certification in first aid from a nationally recognized organization, affecting 54 current residents. Findings Include:1. Residence PolicyThe residence ' s undated First Aid and Cardiopulmonary Resuscitation (CPR) policy read in part: The residence is committed to ensuring the safety and well-being of all residents by maintaining compliance with Regulations 8.5-8.11, which requires at least one certified staff member be available at all times to provide First Aid and CPR. At least one staff member (must be) onsite at all times (and) must have (a) current adult first aid certification from a nationally recognized organization (e.g., American Red Cross, American Heart Association, National Safety Council or American Safety and Health Institute). 2. Record ReviewReview of Staff #8's personnel file, revealed a hire date of 1/5/23 The personnel file revealed Staff #8's first aid certification was issued on 8/7/24 by an organization that was not nationally recognized. Review of Staff #9's personnel file, revealed a hire date of 12/6/22. The personnel file revealed Staff #9's first aid certification was issued on 4/23/24, by an organization that was not nationally recognized. Review of the schedule for Staff #8 and Staff #9 revealed they typically work the 2:00 p.m. to 10:00 p.m. shiftReview of the staff schedules from 11/23/25 through 12/9/25, revealed that from 2:00 p.m. to 10:00 p.m., no staff on duty were first aid certified as required by 6 CCR 1011-1 Chapter 7, Part 8, Section 8.6, on the following dates: 11/23, 11/24, 11/30, 12/1 and 12/7-12/9/25.3. InterviewsOn 12/10/25 at 12:30 p.m., the administrator stated she was aware of the requirement for at least one first aid certified staff member to be made available at all times. The administrator also stated she was unaware that Staff #8 and Staff #9's first aid certifications were not from a nationally recognized organization. On 12/10/25 at 12:30 p.m., the assistant administrator, who is responsible for ensuring staff training, stated she was aware of the requirement for at least one first aid certified staff member to be made available at all times. The assisted administrator also stated she was unaware that Staff #8 and Staff #9's first aid certifications were not from a nationally recognized organization.

Based on records review and interviews, the residence failed to have a readily available roster of current residents, their room assignments, and emergency contact information, affecting 54 current residents. Findings include:On 12/9/25 at 7:57 a.m., the emergency preparedness resident roster, to include names, room numbers, emergency contact information, and a facility diagram, was requested from the administrator via electronic communication. On 12/9/25 at approximately 9:35 a.m., the administrator provided a list of current residents that did not include the room numbers. On 12/9/25 at 9:30 a.m., Staff #6 stated that the administrator or assistant administrator would have the resident roster. On 12/10/25 at 12:30 p.m., the administrator agreed that the roster she provided did not include resident room numbers. She explained that the roster provided is simply a report from the electronic health record that can include room numbers, and is accessible to all staff. However, she acknowledged that staff were unable to access the roster, and stated that she would provide training.

Based on records review and interviews, the residence failed to tailor emergency policies and procedures to its unique risks and circumstances, affecting 54 current residents. Findings include:On 12/9/25 at 7:57 a.m., the residence's emergency policies and procedures (EPPs) were requested. On 12/9/25 at approximately 12:00 p.m., the administrator provided the EPPs. Record review revealed that the documents described the unique risks and circumstances of a sister residence. On 12/10/25 at 12:30 p.m., the administrator agreed the EPPs belonged to a sister residence. She stated they were aware of the issue and were working on updating the documents to meet regulatory requirements.

Based on records review and interviews, the residence failed to ensure the resident care plans reflected the most current assessment information, detailed specific personal service needs along with the staff tasks necessary to meet those needs, affecting two of seven sample residents (#1 and #4). Findings Include:1. Records ReviewResident #1 was admitted to the residence on 3/21/25 with a diagnosis of diabetes. A progress note, dated 10/15/25 at 3:15 p.m., read in part: Resident #1 had an altercation with another resident. During the altercation, the other resident, who was in a wheelchair, turned around after Resident #1 hit the resident in the head. The other resident hit Resident #1's leg with the wheelchair and caused Resident #1 to fall. He refused EMS and any care at the time. The most recent care plan update, dated 11/4/25, read in part, Resident #1 required staff awareness and support when care was declined or resisted, including verbal refusal, pulling away, or nonverbal signs of distress during care tasks. Staff were directed to use a calm tone and familiar staff when possible. If care was repeatedly refused, staff were directed to notify the supervisor and document. Re-approach later unless refusal presents an immediate health or safety concern. The care plan further read staff to provide skin and nail care. However, the care plan did not include specific interventions for refusals, how often staff were to monitor skin and nail health, or indicate any interventions or direction to staff regarding Resident #1's diabetes diagnosis or how to effectively care for those needs. A review of the task administration record (TAR) for November 2025 for Resident #1 revealed that he refused "monitoring and providing cues when needed to assist with dressing and undressing" on 11/1, 11/2, and 11/29 in the morning; and 11/3, 11/4, 11/18, 11/19, 11/23, and 11/26/25 in the evening. No documentation was provided under the section "Resistance to care, provide supervision and monitoring to help prevent/redirect resistance to accepting care." Additionally, no task was assigned for assistance with skin monitoring & nail care. A review of progress notes from 10/15/25 to 12/9/25 revealed no evidence of documentation of any refusal of care from Resident #1. A progress note, dated 12/2/25 at 1:30 p.m., read in part: Resident #1 reported to the activity director toe pain. Resident #1 had a swollen, red, and odorous second toe on the left foot. Resident #1 stated that he was not aware of how this happened. Resident #1 was scheduled for an appointment with the practitioner's office at 1:40 p.m. that day. A progress note, dated 12/2/25 at 5:45 p.m., read in part: Resident #1 was sent to the emergency department (ED) by the practitioner. At approximately 5:15 p.m., residence staff received an update from the ED: "Resident #1 is being admitted to the hospital. Resident #1 had started on antibiotics and was getting an MRI done. Resident #1 may possibly need surgery, but they won't know until after they see the MRI. Resident #1 was also really close to being septic if he wasn't already."A progress note, dated 12/5/25 at 3:15 p.m., read in part: The case manager from the hospital provided an update on Resident #1: "Resident #1 has osteomyelitis in both feet and has had all of his toes removed. He is not participating in PT and OT at the hospital. Resident #1 is not to be up and ambulating, and Resident #1 is up and walking and causing his wounds to bleed."2. InterviewsOn 12/9/25 at 3:50 p.m., the administrator stated that Resident #1 alerted the activity director of toe pain, and was taken to urgent care. Once he got to the appointment, he was taken to the ED and then admitted into the hospital. The administrator agreed that there were inadequate interventions in place surrounding the resident's resistance to care, preventing adequate monitoring of his skin health. On 12/9/25 at 4:00 p.m., the assistant administrator stated when she attempted to monitor Resident #1 while in the shower on the Saturday before he was admitted to the hospital, he refused to allow her into the shower room. She stated that Resident #1 regularly saw his practitioner, but not for podiatry care, and she admitted that no other professionals were considered to help support his podiatry care. On 12/10/25 at 12:30 p.m., the administrator agreed the infection in Resident #1's toe is likely related to his diabetes diagnosis. She agreed that proper monitoring of podiatry needs is especially important with this diagnosis. She agreed that the care plan was not updated to include monitoring of skin and nail care, diabetes and approach to manage resistance to care. She stated that the resistance to care from Resident #1 made it very difficult to monitor his skin health, but acknowledged that more could have been done. On 12/10/25 at 12:30 p.m., the assistant administrator stated that Resident #1's resistance to care made it difficult to properly monitor his skin health. She explained that they attempted to try different staff members to improve cooperation; however, she acknowledged that more should have been done. She agreed that the care plan failed to have updated and effective interventions for resistance to care. 3. Similar deficient practice was found for Resident #4.

Based on record review and interviews, the residence failed to implement fall management policies and procedures, and update each resident's care plan to detail individualized approaches necessary to address fall risk, affecting four of seven sample residents (#1, #4, #5, #6). Specifically, between 10/26 and 12/6/25, Resident #4 sustained a total of five falls. On 10/26/25, Resident #4 sustained a fall and hit her head. However, the residence failed to update Resident #4's care plan with individualized interventions to address Resident #4's fall risk, and staff were unaware of any fall interventions in place for Resident #4. Consequently, on 11/5/25, the resident sustained a fall that resulted in bruising and a swollen ankle; a fall on 12/1/25, that resulted in the resident experiencing head and buttocks pain; and another fall on 11/27/25. Subsequently, due to the residence's failure to implement individualized interventions to address fall risk, Resident #4 sustained a fall on 12/6/25 and was sent out to the hospital with pain in her left hip, right wrist, and a possible head injury. Findings Include:1. Residence PolicyThe residence's undated Fall Management Policy, read in part: Each resident's Care Plan includes strategies to mitigate fall risk, and Care Plans are updated after each fall incident with a detailed intervention plan. 2. Resident #4 was admitted to the residence on 3/21/25. Resident #4 ' s assessment, which also served as the residence's care plan, last updated on 6/17/25, read in part: The resident is at low risk for falls. Staff to perform daily safety checks and alert the licensed nurse of any observable changes in resident's condition. The residence discourages the use of throw rugs and encourages residents to keep their rooms organized with pathways clear of clutter. If assistance devices are used, staff should encourage safe and appropriate usage. A progress note dated 6/1/25, read Resident #4 slipped out of bed and onto the floorOn 10/26/25, a progress note read, Resident #4 had an unwitnessed fall while bending down reaching for medications below her kitchen sink. The resident reported hitting her head, and emergency medical services (EMS) were called, but (Resident #4) refused to be transported to the hospital. On 11/5/25, a progress note read in part, Resident #4 tripped on the rug by her bed and fell forward onto her knees. Resident #4 was observed to have bruising and redness on right knee, which she had been icing. Resident #4 refused EMS services. On 11/6/25, a progress note read in part, Resident #4 said she sprained her ankle as a result of her 11/5/25 fall. As her ankle appeared to be swollen, Resident #4 was transported to the emergency room to have it checked out. On 11/27/25, a progress note read in part, Resident #4 was found on the floor next to her bed. Resident #4 said she needed to use the bathroom and was in a hurry when grabbing her walker and slid out of bed. Staff were able to get Resident #4 up off the floor safely and reported no injury. Vitals were stable, and staff were to monitor per protocol. On 12/1/25, a progress note read in part, Resident #4 was found lying on her back with her head propped against her bathroom wall. Resident #4 said she lost her balance while performing dental hygiene. Resident #4 said her head was tender and her buttocks sore. Resident #4 was helped up, then lost her balance again when she reattempted activity. Resident #4 refused hospital and EMS evaluation. Vitals were taken, and Resident #4 was told to use her walker instead of her cane. On 12/6/25, an incident report read in part, Resident #4 tripped over her laundry basket and fell on her right side. Resident #4 complained of pain in her left hip, right wrist, and said she hit her head. Resident #4 was transported to the hospital by EMS.3. Interviews12/10/25 at 9:45 a.m., Staff #5 stated Resident #4 did not have fall precautions as she was not a fall risk. 12/10/25 at 9:55 p.m., Staff #6 stated that staff checked on her; however, there were no scheduled checks. Staff #6 stated that Resident #4 used her call button. 12/10/25 at 9:55 p.m., Staff #7 stated she would check on Resident #4; however, she was not required to check on her since there were no monitoring or interventions in the resident's care plan. On 12/10/25 at 12:30 p.m., the assistant administrator, who was responsible for updating resident care plans, stated that the assessments and care plans were not updated with individualized interventions to manage falls, and she was still in the process of updating them. 4. Similar deficient practice was found with Residents #1, #5, and #6.

Based on records review and interviews, the residence failed to comply with authorized practitioner orders, affecting five of seven sample residents (#1, #2, #3, #6, #7). Findings Include:1. Record ReviewResident #7 was admitted to the residence on 10/18/24, with a diagnosis including pulmonary embolism. Resident #7 ' s most recent care plan, dated 8/27/25, read in part, "resident requires licensed staff assistance with handling changes to prescription and/or communicating with pharmacy and prescriber."A practitioner's order, dated 8/25/25, directed the residence to administer Eliquis 5 mg twice daily. Review of Resident #7 ' s September, October, November and December 2025 Medication Administration Records (MARS), revealed the residence failed to administer Eliquis 5 mg as prescribed, for both doses on 9/27-9/30, 10/1-10/14, 11/1-11/4, and 12/8/25, because this medication was not available. On 10/14/25 the residence faxed an order to Resident #7 ' s practitioner that read (Resident #7) has not had her Eliquis 5 mg since 9/27/25. The practitioner wrote a new order on 10/14/25 that read in part: "Please give samples (of) Eliquis 5 mg twice a day." 2. InterviewsOn 12/9/25 at approximately 4:00 p.m., Resident #7 stated she was aware that she had not received her Eliquis. On 12/10/25 at approximately 4:30 p.m. the administrator and assistant administrator acknowledged it was their responsibility to ensure resident medications were administered as ordered, and stated Resident #7 ' s practitioner was contacted when her Eliquis could not be obtained from the pharmacy and was provided with a temporary supply. When the samples ran out, it was noted that Resident #7 ' s daughter obtained Eliquis and delivered it to the facility. The administrator acknowledged they would expect compliance with the regulation. She further stated if a resident runs out of their prescribed medication in the future, they will contact the practitioner as soon as possible to alert them that the resident is out of their prescribed medication they will request an order to discontinue it until the medication is refilled. Similar deficient practice was identified for Residents #1, #2, #3 and #6.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1 Chapters 2 and 7.8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both. 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum:(A) The individual designated by the assisted living residence to receive involuntary discharge grievances.(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence.(D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or(2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence.(a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness ' s name and contact information, and shall keep that information as part of the grievance documentation.(E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an appeal: " If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation. "(F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.(G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part.(H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending.(I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board,(2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and(3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 10.5 Each assisted living residence shall identify its highest potential risk and hold routine drills to facilitate staff and resident response to that risk. There shall be written documentation of such drills. 10.6 Each assisted living residence ' s emergency policies shall address, at a minimum, all of the following items:(A) Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations;(F) Storage and preservation of medications;(H) Protection and transfer of health information as needed to meet the care needs of residents; and12.2.2 Infection Control Officer(A) Applicability(1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated:(a) Assisted Living Residences;(c) Facilities for Persons with Intellectual and Developmental Disabilities, including both Group Homes and Intermediate Care Facilities for persons with intellectual and developmental disabilities.(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility ' s Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider or the Department ' s training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(a) Infection Control Officers at nursing care facilities and intermediate care facilities for persons with intellectual and developmental disabilities shall complete at least nineteen (19) hours of initial training.(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(2) Completing a minimum of 1.5 hours of continuing education in infection prevention and control on an annual basis from a nationally-recognized provider or the Department ' s training program sufficient to stay current on changing guidance and requirements in the field;(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer ' s guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring recommended vaccines for infectious diseases are available to staff and residents inside their facility on an annual basis. 14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. 18.9 The face sheet shall be updated at least annually and contain the following information: (K) Resident's current diagnoses21.2 The assisted living residence grounds shall be maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction. 21.4 Porches, stairs, handrails, and ramps shall be maintained in good repair. 23.3 Screens or other pest control measures shall be provided on all exterior openings except where prohibited by fire regulations. Assisted living residence doors, door screens, and window screens shall fit with sufficient tightness at their perimeters to exclude pests.

A revisit survey was completed on 4/27/23 for all previous deficiencies cited on 10/13/22. The facility is in compliance with all deficiencies were cited.

A revisit survey was completed on 4/27/23 for all previous deficiencies cited on 10/13/22. The facility is in compliance with all deficiencies were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally