Villa Pueblo Assisted Living

A revisit survey was completed on 12/10/24 for previous deficiencies cited on 10/17/2024. The agency is in compliance with all regulations surveyed. 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

A complaint revisit was completed on 10/17/24 for the previous deficiency cited on 1/9/23. The residence is in compliance with all regulations surveyed.

A relicensure survey was completed on 10/17/24. Deficiencies were cited. Based on interview and record review the residence failed to ensure there was at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques, affecting six current residents. Findings include:1. Record review On 10/16/24 at 8:00 a.m., a staff schedule along w.. Based on observation and record review the residence failed to maintain a physically safe and sanitary environment, affecting six current residents.Findings include:On 10/16/24 during an onsite environmental tour, the following was observed:The residence' s main shower room had missing tiles on the floor and chipped grout between the tiles, a sin.. Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy, affecting six current residents.On 10/16/24, the residence' s involuntary discharge grievance policy did not include all of the required elements.On 10/17/24 at 2:00 p.m., the senior executive director reported that t.. Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting three of three sample residents (#1-#3).Findings include:1. Resident #1 was admitted to the residence on 9/12/22 with a diagnosis of Alzheimer' s dis.. Based on record review and interview the residence failed to have at least one staff member responsible for the infection prevention and control program, affecting six current residents.Findings include:On 10/16/24 at 11:00 a.m., proof of the designated infection prevention and control staff member was requested from the residence; however, i.. Based on record review and interview the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting six current residents.Findings include:On 10/16/24, the residence' s visitation policy did not include all of the required elements... Based on record review and interview, the residence failed to ensure that each staff member met the dementia training requirements in 7.9(B), affecting six current residents.Findings include:On 10/16/24 at approximately 3:45 p.m., personnel files for Staff #1-#3 revealed no evidence that the direct care staff members met the dementia train.. Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting six current residents.Findings include:On 10/16/24 at 2:24 p.m., documentation of quarterly medication audits was requested, however, none were provided. .. 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 7.10.1 The assisted living residence shall have readily available a roster of current residents, t..

A licensure complaint, prompted by #CO30529, was completed on 1/9/23. A deficiency was cited. Based on record review and interview, the residence failed to ensure their emergency policies addressed the protection and transfer of health information as needed to meet the care needs of residents, affecting one former resident (#3). Specifically, Former Resident #3 had a medical orders for scope of treatment (MOST) form that indicated he did not want intensive care or intubation in the event of an emergency. The resident requested to be sent to the hospital on 12/25/22 due to lethargy and not feeling well. When emergency services arrived, residence staff failed to locate the resident' s MOST form and it was not provided to emergency services personnel or sent to the hospital until 12/26/22. Subsequently, Former Resident #3 received critical care including intubation and ventilation, contrary to his wishes as indicated on his MOST form and causing unnecessary suffering. Findings include:1. Reference and Residence PolicyAccording to the Center for Improving Value in Healthcare, "The Medical Orders for Scope of Treatment (MOST) form is a 1-page, 2-sided document that consolidates and summarizes patient preferences for key life-sustaining treatments: CPR, medical interventions and artificially administered nutrition." CIVHC (2022) MOST Program Overview, retrieved from:https://www.civhc.org/programs-and-services/most-program/The residence' s und.. 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 7.7.8 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows:(B) The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training, and shall include, but is not limited to, the following topics:(1) Overview of state regulatory oversight applicable to the assisted living residence;(2) Person-centered care;(3) The role of and communication with external service providers;(4) Recognizing behavioral expression and management techniques, as appropriate for the population being served;(5) How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served;(6) Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating e..