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 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) on.. 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 Decem.. 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 c.. 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 provide.. 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 Rule2. 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)..

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 Regulat.. 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 Resid.. 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 com.. 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., rea.. 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 .. 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 sist.. 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..

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