La Villa Grande Care Center

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 80. This was evidenced by: 1) Fire Doors (annually)(80 5.2): Done monthly, report from June 2025 shows 9 failed fire doors .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by: 1) Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Weekly Done, Monthly CCA not performed .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 25. This was evidenced by: 1) Annual: 11.1.24 Excel Fire, 3 antifreeze loops exist, report shows reading for 2, appears to be missing the mainten.. Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by: 1) Egress pathway from dinning hall obstructed to public way, need directional exit sign pointing to pathway and nee.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) The therapy gym, blue spruce east, is open to corridor and needs to be protected per 19.3.6.1 or have door closur.. *** CITATION TEXT NOT FOUND *** 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 The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). Initial comments, (ID Prefix Tag # K 000), are informational only, representing the facility' s general characteristics. ..

A licensure survey was completed on 5/19/25 to 5/22/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#28) of three residents out of 37 sample residents.Resident #28, who was at risk for falls, was admitted on 4/17/23 with diagnoses of dementia, history of falling, abnormalities of gait and mobility, weakness and insomnia. On 5/1/25 the physician recommended the resident transition to a walker without wheels for safety and have a physical therapy (PT) evaluation. However, Resident #28 continued to use her four-wheel walker and a PT evaluation was not conducted until 5/13/25.Resident #28 fell three times in less than a week (on 5/6/25, 5/9/25 and 5/10/25). She was identified to have high blood pressure after the falls and was discovered to have a urinary tract infection (UTI) after the last fall on 5/10/25, increasing her risk for falls. All three of the falls occurred in the early morning hours when Resident #28 got out of bed independently. However, the facility failed to identify a pattern with the falls. Two of the three falls resulted in injuries, including facial injuries. The 5/10/25 fall resulted in the resident going to the hospital for stitches to her head. Specifically, the facility failed to identify and implement timely interventions for Resident #28 to help decrease her risk for patterned falls and risk of falls with injury. Findings include:I. Facility policy and procedureThe Falls-Clinical Protocol policy, revised September 2012, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. The policy read in pertinent part, "For an individual who has fallen, staff will attempt to find possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in the fall. Often multiple factors in varying degrees contribute to a fall problem.""The staff and the physician will monitor and document the individual' s response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at a greater risk for serious adverse c..