Village Assisted Living LLC, the

A revisit survey was completed on 9/19/25 for previous deficiencies cited on 8/5/25. 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 revisit survey was completed on 9/19/25 for previous deficiencies cited on 8/5/25. 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 certification revisit was completed on 8/5/25 for the previous deficiencies cited on 10/31/22. A deficiency was cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 2/15/25. Based on observation and interview, the facility (residence) failed to store medications under proper conditions with regard to safety, affecting seven current members (residents). This deficiency was cited previously during a recertification survey on 10/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:Throughout the onsite visit on 8/5/25 from 7:45 a.m. and 12:00 p.m., the medication refrigerator which was located in the dining area, was unlocked and accessible to residents. Resident #10, #11 and #13 walked passed the unlocked refrigerator which contained three boxes of Resident #12' s Vyzulta 0.024% ophthalmic solution. On 8/5/25 at approximately 12:00 p.m., the administrator stated she opened the refrigerator the morning of the onsite investigation so Resident #12' s refrigerated medication could be observed by the surveyor; however, forgot to lock the refrigerator afterwards. The administrator stated the deficiency was not corrected since the lock on the refrigerator would get stuck and it was not easy to lock.

A relicensure survey with complaint #CO39709 was completed on 8/5/25. Deficiencies were cited. Based on observation and interview, the residence failed to store refrigerated medications in a refrigerator that was not accessible to residents, affecting seven current residents.Findings include:Throughout the onsite visit on 8/5/25 from 7:45 a.m. and 12:00 p.m., the medication refrigerator which was located in the dining area, was unlocked and accessible to residents. Resident #10, #11 and #13 walked passed the unlocked refrigerator which contained three boxes of Resident #12' s Vyzulta 0.024% ophthalmic solution. On 8/5/25 at approximately 12:00 p.m., the administrator stated she opened the refrigerator the morning of the onsite investigation so Resident #12' s refrigerated medication could be observed by the surveyor; however, forgot to lock the refrigerator afterwards. Based on record reviews and interview, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting one sample resident (#10) for whom the residence administers controlled substances.Findings include:Resident #10 was admitted to the residence on 7/20/23 with a diagnosis of bipolar depression.A practitioner' s order for Resident #10 dated 12/9/24, directed the residence to administer lorazepam 0.5 mg twice daily.Review of the July and August 2025 controlled count record revealed qualified medication administration persons (QMAPs) failed to jointly sign documentation regarding the results of the count at the time it occurred as follows:At 7:30 a.m. on 7/5, 7/6, 7/7, 7/11, 7/12-7/16, 7/30, 8/1-8/4/25 and 7:30 p.m. on 7/3, 7/4, 7/5, 7/6, 7/7, 7/10, 7/12-7/16, 7/24, 7/30 and 8/1-8/3/25.On 8/5/25 approximately 12:00 p.m., the administrator stated staff worked 12-hour shif.. 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 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer. (A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI).

A recertification survey with complaint #CO39710 was completed on 8/5/25. A deficiency was cited. Based on observation and interview, the facility (residence) failed to store medications under proper conditions with regard to safety, affecting seven current members (residents). Findings include:The medication refrigerator was located in the dining area. Throughout the onsite visit on 8/5/25 from 7:45 a.m. and 12:00 p.m., the medication refrigerator which was located in the dining area, was unlocked and accessible to residents. Resident #10, #11 and #13 walked passed the unlocked refrigerator which contained three boxes of Resident #12' s Vyzulta 0.024% ophthalmic solution. On 8/5/25 at approximately 12:00 p.m., the administrator stated she opened the refrigerator the morning of the onsite investigation so Resident #12' s refrigerated medication could be observed by the surveyor; however, forgot to lock the refrigerator afterwards. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary.The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.7000.8.7409.E.1 Colorado Adult Protective Services (CAPS) and Criminal Background Checks Provider Agencies shall conduct criminal background checks and reference checks and compare the employee ' s/independent Contractor ' s name against the list of all currently excluded individuals maintained by the Office of Inspector General prior to employing staff or independent Contractors to provide services and support to Members. All costs related to obtaining a criminal background check shall be borne by the Provider Agency. Background checks shall be completed every five years for each employee and Contractor who provides direct care to Members.

A licensure revisit was completed on 8/5/25 for all previous deficiencies cited on 10/31/22. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25. Based on observation and interview, the residence failed to store refrigerated medications in a refrigerator that was not accessible to residents, affecting seven current residents.This deficiency was cited previously during a relicensure survey on 10/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:Throughout the onsite visit on 8/5/25 from 7:45 a.m. and 12:00 p.m., the medication refrigerator which was located in the dining area, was unlocked and accessible to residents. Resident #10, #11 and #13 walked passed the unlocked refrigerator which contained three boxes of Resident #12' s Vyzulta 0.024% ophthalmic solution. On 8/5/25 at approximately 12:00 p.m., the administrator stated she opened the refrigerator the morning of the onsite investigation so Resident #12' s refrigerated medication could be observed by the surveyor; however, forgot to lock the refrigerator afterwards. The administrator stated the deficiency was not corrected since the lock on the refrigerator would get stuck and it was not easy to lock. Based on record reviews and interview, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting one sample resident (#10) for whom the residence administers controlled substances.This deficiency was cited previously during a relicensure survey on 10/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:Resident #10 was admitted to the residence on 7/20/23 with a diagnosis of bipolar depression.A practitioner' s order for Resident #10 dated 12/9/24, directed the residence to administer lorazepam 0.5 mg twice daily.Review of the July and August 2025 controlled count record revealed qualified medication administration persons (QMAPs) failed to jointly sign documentation regarding the results of the count at the time it occurred as follows:At 7:30 a.m. on 7/5, 7/6, 7/7, 7/11, 7/12-7/16, 7/30, 8/1-8/4/25 and 7:30 p.m. on 7/3, 7/4, 7/5, 7/6, 7/7, 7/10, 7/12-7/16, 7/24, 7/30 and 8/1-8/3/25.On 8/5/25 approximately 12:00 p.m., the administrator stated staff worked 12-hour shifts. The administrator stated she was aware of the requirement for two ..