Residence at Village Green LLC, the

A relicensure survey with complaint #CO40547 and #CO41413 was completed on 1/14/26. Deficiencies were cited. Based on interviews and record review, the residence failed to complete a reassessment whenever the resident had a change from baseline status, affecting one of five sample residents (Former Resident #8).Findings include: Findings include:Former Resident #8 was admitted to the residence on 1/2/24 with a diagnosis of stroke. She also has a diagnosis of high blood pressure and dizziness.An assessment in Former Resident #8' s record was last completed in January 2024 when admitted.A signed practitioner' s order dated 05/11/25, in Former Resident #8' s chart read she could self-administer her medications, including lasartan 25mg tablet daily for hypertension (high blo.. Based on observation and interviews, the residence failed to maintain grounds to protect residents from slopes, holes and other hazards, affecting 60 current residents.Findings include:On 1/14/26 from approximately 1:00 p.m. to 1:15 p.m., an environmental tour revealed a concrete walkway to the courtyard in the middle of the residence. However, the edge of the sidewalk had a drop off of 2.6 inches, which posed a hazard. On 1/13/26 and 1/14/26 residents were observed exiting the dining room doors into the courtyard and walking east into the connecting residence. The west side of the exterior of the residence, the corner edge of the sidewalk had a drop of 3.8 inches. On 1/13/26 and 1/14.. Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 60 current residents. Findings include:Staff #4 had a CPR certification, however the certification was not from a nationally recognized organization, as required. The January 2026 staff schedule revealed the following 10:00 p.m. to 6:00 a.m. shifts did not have at least one staff member onsite who had current CPR certification from a nationally recognized organization:1/5, 1/9, 1/11-1/13, and 1/15/26, for a total of six shifts. On.. Based on record review and interviews, the residence failed to document accurate information in the medication administration record, including any medication omissions, refusals, and resident-reported responses to medications affecting five out of six sample residents (#1, #2, #4, #5 and #8).Findings include:Resident #2 was admitted to the residence on 5/23/25 with diagnoses including diabetic ketoacidosis, hypertension, chronic pain syndrome, hyperlipidemia, lactic acidosis, and leukocytosis. A written practitioner' s order dated 5/23/25 directed the residence to administer. December 2025 and January 2026 MAR revealed blank spaces indicating undocumented doses for the f.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident ' s representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purpo..

A recertification survey with complaint #CO40549 and #CO41412 were completed on 1/14/26. Deficiencies were cited. Based on observation and interviews, the facility (residence) failed to protect the right to privacy and dignity of members (residents) by failing to provide a lockable bathroom, affecting 60 current residents.Findings include:ObservationOn 1/14/26 at approximately 12:27 p.m., an environmental tour of the residence revealed two of the facility bathrooms in the hallway did not have a lock on the doors to access the bathroom.InterviewOn 1/14/26 a.. Based on observation, record review and interview, the agency failed to adequately document quarterly monitoring of the member' s ability for independent medication administration to determine that the medication was taken correctly for one member (#8) of eight sampled members.Findings include: Record ReviewOn 1/13/26 at 9:00 a.m., there are no self-administration of medication quarterly audits to determine if members can take medications as prescribed.Inter.. Based on observations and interviews, the facility (residence) failed to provide an outdoor area accessible to members (residents) without staff assistance that is well maintained for 60 current residents.Findings include:On 1/14/26 from approximately 1:00 p.m. to 1:15 p.m., an environmental tour revealed a concrete walkway to the courtyard in the middle of the residence. However, the edge of the sidewalk had a drop off of 2.6 inches, which posed a hazard. On 1.. Based on observations and interviews, the facility (residence) failed to provide members (residents) with social and recreational engagement opportunities in an outside the setting, affecting 3 current residents.Observation: On 1/14/26 at approximately 9:00 a.m. it was observed that a community outing was scheduled to take members to the Dollar Tree store. Several members attended but there were no residents in a motorized chair who participat.. Based on record review and staff interview, the facility failed to ensure medication administered to or refused by members was documented for five out of six sample members (#1, #2, #4, #5 and #8).Findings include:Resident #2 was admitted to the residence on 5/23/25 with diagnoses including diabetic ketoacidosis, hypertension, chronic pain syndrome, hyperlipidemia, lactic acidosis, and leukocytosis. A written practitioner' s order dated 5/23/25 directed th.. 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 60 current residents.Findings include:Staff #4 had a CPR certification, however the certification was not from a nationally recognized organization, as required. The January 2026 staff schedule reveale.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.7000.8.7410 Rendering services according to the Person-Centered Support PlanA. Provider Agencies shall provide all Provider Agencies identified in the Person-Centered Support Plan (PCSP) a copy of the PCSP. Provide..