Villa Grove Assisted Living

A certification complaint, prompted by #CO40295, was completed on 6/16/25. Deficiencies were cited. Based on record review and interview the facility failed to provide protective oversight affecting one Former Member (#1). Findings include:1. Record review:Former Member #1 was admitted to the residence on 6/27/24 with a diagnosis of Schizoaffective disorder, bipolar type. The Member was involuntarily discharged on 6/5/24. A court document, dated 12/8/20, read in pertinent: Former Resident #1 was appointed a court ordered guardian related to a long history of "mental illness, instability with care, treatment and living environments. A progress note, dated 5/29/25, read in pertinent: Former Member #1 was asked to allow staff to hold his cigarettes and lighter after an incident occurred where Former Member #1 was documented as attempting to extinguish a smoldering duffle bag in his room of the facility. Former Member #1 refused and ultimately told the administrator he was walking to a homeless shelter. 2. InterviewOn 6/16/25 at 12:30 p.m., the administrator said Former Member #1 left the facility on foot and stated he was going to a homeless shelter. The administrator said, shortly thereafter, he [administrator] got in his car and drove around looking for Former Member #1. The administrator said he saw Former Member #1 walking in the direction of a homeless shelter. The administrator said he did not engage in conversation with Former Member #1, no.. Based on record review and interviews the facility (residence) failed to provide a 30 days' notice of discharge, affecting one Former Member (resident) (#1). Findings include:1. Record reviewFormer Resident #1 admitted the residence on 6/27/24 with a diagnosis of Schizoaffective disorder, bipolar type.A progress note, dated 5/29/25 at 9:15 p.m., read in part: After a fire alarm sounded in the residence the source was smoke from a smoldering bag in Former Resident #1' s room. It was documented that when staff arrived, Former Resident #1 stated he was "putting it out" and was running water over a bag that was smoking and had red embers on it. The administrator was notified and arrived at the residence at 9:35 p.m. and asked Former Resident #1 to allow the staff to hold his cigarettes and lighter for the duration of the night and to engage in a behavioral plan to avoid further safety issues. Ultimately the resident declined and left on foot to stay at a homeless shelter. On 6/16/25 at 10:19 a.m., an electronic correspondence was received from Former Resident #1' s external case management team that read in pertinent: Former Resident #1 was being discharged due to safety concerns, specifically, he had a smoldering duffle bag in his room. Former Resident #1 was asked to comply with rules and regulations of residence and declined to do so. 2. InterviewOn 6/16/25 at 10:15 ..

A Licensure complaint, prompted by #CO40294, was completed on 6/16/25. Deficiencies were cited. Based on record review and interview the residence failed to have an involuntary discharge grievance policy, affecting 16 current and one former resident (#1). On 6/16/25 at 10:00 a.m. the policy and procedure book was provided and lacked a policy for the involuntary discharge grievance process. On 6/16/25 at 12:30 a.m., the administrator said he knew there was a process for involuntary discharges but was unaware the residence needed a policy. The administrator said the residence did not have a policy for involuntary discharges. Based on record review and interview the residence failed to make available, either directly or indirectly, protective oversight, including but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one former resident (#1) and two out of three sample residents (#2, #3) . Findings include:1. Record review:Former Resident #1 admitted the residence on 6/27/24 with a diagnosis of Schizoaffective disorder, bipolar type. The resident was involuntarily discharged on 6/5/25.A court document, dated 12/8/20, read in pertinent: Former Resident #1 was appointed a court ordered guardian related to a long history of "mental illness, instability with care, treatment and living environments. A progress note, dated 5/29/25, read in pertinent p.. Based on record review and interview the residence failed to provide a written notice of involuntary discharge which includes all required elements, affecting one Former Resident (#1). (Cross-reference S0816)Finding include:1. Record reviewFormer Resident #1 admitted the residence on 6/27/24 with a diagnosis of Schizoaffective disorder, bipolar type.A progress note, dated 5/29/25 at 9:15 p.m., read in part: After a fire alarm sounded in the residence the source was smoke from a smoldering bag in Former Resident #1' s room. It was documented that when staff arrived, Former Resident #1 stated he was "putting it out" and was running water over a bag that was smoking and had red embers on it. The administrator was notified and arrived at the residence at 9:35 p.m. and asked Former Resident #1 to allow t.. Based on record review and interviews the residence failed to evaluate a resident for discharge, affecting one Former resident (#1). (Cross-Reference 816) Findings include:1. Record reviewFormer Resident #1 was admitted to the residence on 6/27/24 with a diagnosis of Schizoaffective disorder, bipolar type.A hospital discharge note, dated 6/5/25, read Former Resident #1 requested to return to the residence, however, there was a question of the residence allowing his return. 2. InterviewOn 6/16/25 at 12:30 p.m., the administrator said he was notified by Former Resident #1' s external case management team that Former Resident #1 was cleared to discharge from hospital and requested to return to the residence. The administrator said he declined to assess Former Resident #1 for return and ..

A recertification survey was completed on 1/9/24. A deficiency was cited. Based on interviews and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting one sample participant (resident #1) who was administered medications throughout December 2023 and January 2024.Findings include: 1. Residence PolicyThe residence' s Authorized Provider Orders policy, dated 6/1/21, read in part: "(the residence) will ensure that orders for medications, services and care plans are complete and in compliance with the State of Colorado regulations ... all medication orders must include ... date of the order (and the) ordering practitioner' s signature."2. Resident #1 was admitted to the residence on 9/9/19 with a diagnosis of schizophrenia.DonepezilThe December 2023 and January 2024 medication administration records (MARs) read Resident #1 was administered donepezil 5 mg once daily on 12/7-12/28/23 and 1/1-1/9/24 for a total of 31 doses. However, the residence was unable to provide a signed practitioner order for the medication. Atorvastatin 10 mgThe December 2023 MAR read Resident #1 was administered atorvastatin 10 mg once daily from 12/1-12/19/23 for a total of 19 doses. Additionally, the December 2023 MAR read the medication was discontinued on 12/19/23. However, the residence was unable to provide signed practitioner' s orders to begin or discontinue the medication. Atorvastatin 20 mgThe January 2024 MAR read Resident #1 was administered atorvastatin 20 mg once daily from 1/1-1/9/24 for a total of nine doses. However, the residence was unable to provide a signed practitioner order for the medication. 3. InterviewsOn 1/9/24 at 10:40 a.m., Staff #3 stated she was not able to find signed practitioner' s orders for atorvastatin 10 or 20 mg, or for donepezil 5 mg, in Resident #1' s record. On 1/9/24 at approximately 12:20 p.m., the administrator stated the house manager who was on leave was responsible for managing and ordering medications; however, the other qualified medication administratio..