Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 18, 2025
Visit Reason
The inspection was conducted due to a significant medication error involving warfarin administration at LA Villa Grande Care Center, resulting in immediate jeopardy to resident health or safety.
Findings
The facility failed to prevent a significant medication error when Resident #8 received warfarin twice daily instead of once daily as ordered, and failed to properly document and monitor INR levels, placing the resident at risk for serious harm. The facility corrected the deficient practice prior to the onsite investigation and implemented a plan of correction including staff education, audits, and updated procedures.
Deficiencies (1)
Failure to prevent a significant medication error involving warfarin administration resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents reviewed for medication errors: 3
Residents affected: 1
Warfarin doses administered: 2
INR levels: 4.5
Correction date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding warfarin order verification and monitoring practices |
| Director of Nursing | DON | Provided plan of correction and described auditing and education efforts |
| Staff Development Coordinator | SDC | Provided education on warfarin policy to nursing staff |
| Nurse Practitioner | NP | Interviewed about warfarin administration protocol and monitoring |
Inspection Report
Routine
Census: 37
Deficiencies: 9
Date: May 22, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident rights, abuse prevention, psychotropic medication use, restorative care, fall prevention, medication error rates, food service quality, and infection control.
Findings
The facility was found deficient in multiple areas including failure to assess resident self-administration of medications, inadequate posting of State Survey Agency contact information, failure to prevent resident-to-resident abuse, inappropriate use and documentation of psychotropic medications, failure to provide consistent restorative ambulation services, inadequate fall prevention interventions resulting in multiple falls with injury, medication administration errors exceeding acceptable rates, serving food at inappropriate temperatures, and lapses in infection prevention practices including hand hygiene and use of personal protective equipment.
Deficiencies (9)
Failed to ensure assessment and physician order for self-administration of medications for Resident #15.
Failed to post State Survey Agency contact information in a manner accessible and understandable to residents.
Failed to prevent resident-to-resident abuse involving Residents #68, #71, and #65.
Failed to ensure appropriate use and documentation of psychotropic medications for Residents #48, #61, #5, and #387.
Failed to provide consistent restorative nursing services through the walk-to-dine program for Resident #80.
Failed to provide adequate supervision and timely interventions to prevent falls for Resident #28, resulting in multiple falls and injury.
Medication error rate was 7.69%, exceeding the acceptable rate of less than 5%. Errors included incorrect medication administration and documentation for Resident #15.
Failed to ensure food was served at palatable temperatures and with acceptable taste and texture.
Failed to ensure consistent hand hygiene and use of personal protective equipment (PPE) when providing meal assistance and direct care to residents, including failure to don PPE for residents on enhanced barrier precautions.
Report Facts
Medication error rate: 7.69
Residents affected by medication errors: 1
Residents affected by abuse: 2
Falls by Resident #28: 3
BIMS scores: 14
BIMS scores: 6
BIMS scores: 3
Temperature of Salisbury steak: 111.6
Temperature of oven-fried potatoes: 103
Temperature of spinach: 109.5
Temperature of chicken and rice stew: 114.3
Temperature of coconut pie: 67.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in medication error finding related to Resident #15 |
| RN #1 | Registered Nurse | Interviewed regarding medication self-administration and walk-to-dine program |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication administration, fall prevention, and infection control |
| NHA | Nursing Home Administrator | Interviewed regarding multiple findings including policy, fall prevention, and infection control |
| CC | Corporate Consultant | Interviewed regarding multiple findings including fall prevention and infection control |
| IP | Infection Preventionist | Interviewed regarding infection control practices and education |
| CNA #13 | Certified Nurse Aide | Observed and interviewed regarding hand hygiene lapses during meal assistance |
| CNA #14 | Certified Nurse Aide | Observed and interviewed regarding hand hygiene lapses during meal assistance |
| DOR | Director of Rehabilitation | Interviewed regarding walk-to-dine program and physical therapy communication |
| DM | Dietary Manager | Interviewed regarding food temperature and palatability concerns |
| Consultant Pharmacist | Interviewed regarding medication errors and psychotropic medication use |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 8, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care and food safety practices at LA Villa Grande Care Center.
Findings
The facility failed to ensure professional standards of care related to fluid intake monitoring and diabetic diet adherence for two residents, resulting in minimal harm. Additionally, the kitchen failed to maintain sanitary food storage and handling practices, including use of dented cans, moldy produce, undated food items, and improper hand hygiene by staff.
Deficiencies (3)
Failed to monitor and manage Resident #9's fluid intake effectively, resulting in hospitalization for fluid overload.
Failed to provide Resident #3 with education on risks of not following diabetic diet and failed to update care plan to document refusals.
Failed to store, prepare, distribute, and serve food in a sanitary manner, including use of dented cans, moldy and undated produce, and improper hand hygiene during food handling.
Report Facts
Resident weight gain: 35
Fluid intake exceedances: 9
Fluid intake exceedances: 7
Fluid intake exceedances: 2
Physician fluid restriction order: 2500
Physician fluid restriction order: 3000
MDS BIMS score: 11
MDS BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Interviewed regarding Resident #3's diet adherence and family food brought in. |
| Licensed Practical Nurse #2 | LPN | Interviewed about documentation and communication of diet refusals. |
| Registered Nurse #2 | RN | Interviewed about education efforts for diet adherence. |
| Licensed Practical Nurse #1 | LPN | Interviewed about physician notification and documentation of diet refusals. |
| Registered Dietitian | RD | Interviewed about diet adherence, fluid restriction orders, and kitchen oversight. |
| Director of Nursing | DON | Interviewed about expectations for diet adherence education and fluid restriction orders. |
| Dietary Manager | DM | Interviewed about food storage, handling, and removal of moldy/dented items. |
| Cook #1 | CK | Observed and interviewed regarding food preparation and handling. |
| Cook #2 | CK | Observed and interviewed regarding glove use and food handling. |
| Registered Nurse #1 | RN | Infection preventionist interviewed about hand hygiene training and audits. |
Inspection Report
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for LA Villa Grande Care Center, summarizing the findings of a regulatory survey completed on 2024-02-12.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 16
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, infection control, dietary services, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to timely and properly address resident grievances, inaccurate resident assessments, inadequate infection control practices, insufficient nursing and dietary staffing, improper food handling and storage, failure to provide timely call light responses, and incomplete resident immunization documentation. Specific issues included unresolved resident grievances, inaccurate MDS documentation, delayed meal service, improper wound care techniques, and malfunctioning call light systems.
Deficiencies (16)
Failure to follow up on resident grievances in a timely and effective manner.
Failure to ensure residents' rights to formulate advance directives and proper proxy decision making.
Failure to inform resident or representative in writing of bed hold policy upon hospital transfer.
Failure to permit resident to return to facility after hospitalization due to inadequate assessment and communication.
Failure to ensure accurate resident assessments on MDS including transfer status, vaccination status, and medication use.
Failure to provide adaptive equipment to maintain resident's ability to feed himself.
Failure to assist resident in gaining access to audiology services despite hearing impairment.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including timely interventions and proper wound care techniques.
Failure to provide sufficient nursing staff to meet resident needs and timely answer call lights.
Failure to provide sufficient dietary and food and nutrition staff leading to prolonged meal wait times and resident dissatisfaction.
Failure to ensure therapeutic diets are prescribed and implemented correctly, including proper thickening of liquids.
Failure to store, prepare, distribute, and serve food in a sanitary manner, including improper food temperatures, unclean kitchen surfaces, and improper storage of health shakes.
Failure to implement policies and procedures for flu and pneumococcal vaccinations, resulting in residents not being offered or receiving vaccinations timely.
Failure to ensure a working call system in resident bathrooms and timely repair of malfunctioning call lights.
Failure to ensure residents were provided opportunity for hand hygiene before meals and staff performed hand hygiene between tasks; improper wound care infection control practices.
Failure to thoroughly and accurately explain binding arbitration agreements to residents and representatives, including right to rescind.
Report Facts
Call light response times: 22
Pressure injury size: 12.2
Pressure injury size: 11.8
Pressure injury size: 7.1
Pressure injury size: 5
Pressure injury size: 5
Pressure injury size: 3.9
Pressure injury size: 2
Pressure injury size: 2.4
Pressure injury size: 2
Pressure injury size: 2.1
Pressure injury size: 1.5
Pressure injury size: 2.5
Pressure injury size: 2.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in thickened liquid preparation and administration observation and interview. |
| ADON | Assistant Director of Nursing | Named in wound care observation and interview, and call light system issue. |
| DM | Dietary Manager | Named in dietary staffing and food service interviews and observations. |
| CNA #2 | Certified Nurse Aide | Named in feeding assistance and thickened liquid awareness. |
| CNA #3 | Certified Nurse Aide | Named in dietary service and thickened liquid preparation interviews. |
| LPN #2 | Licensed Practical Nurse | Named in thickened liquid preparation interview. |
| LPN #3 | Licensed Practical Nurse | Named in thickened liquid preparation interview. |
| IP | Infection Preventionist | Named in infection control policy and practice interview. |
| MSD | Maintenance Service Director | Named in call light system and kitchen maintenance interviews. |
| CSC | Central Supply Clerk | Named in arbitration agreement explanation interview. |
| ROM | Regional Operations Manager | Named in arbitration agreement and resident return interviews. |
| NHA | Nursing Home Administrator | Named in arbitration agreement and call light system interviews. |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 19, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, focusing on compliance with infection control policies and procedures.
Findings
The facility failed to maintain an effective infection prevention and control program, including inadequate hand hygiene practices by housekeeping staff, potential cross-contamination of high-touch surfaces, and inconsistent cleaning of shared equipment such as transfer devices.
Deficiencies (3)
High touch surface areas were not potentially cross contaminated.
Consistent hand hygiene was not performed between doffing and donning gloves.
Shared equipment, specifically transfer devices, was not consistently wiped down between resident use.
Report Facts
Residents affected: Some
COVID positive residents: 23
COVID outbreak dates: Outbreak period from 3/22/23 to 5/1/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Observed performing cleaning with inadequate hand hygiene and cross-contamination practices |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding hand hygiene importance |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding shared equipment disinfection practices |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding shared equipment disinfection practices |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control training, audits, and COVID outbreak |
| Housekeeping Director | Housekeeping Director | Interviewed about staff training and cleaning procedures |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about ongoing staff education on infection control |
| Director of Nursing | Director of Nursing | Interviewed about ongoing staff education on infection control |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #1, who required two-person assistance but was provided care by a single CNA, resulting in injury.
Complaint Details
The visit was complaint-related due to a fall incident involving Resident #1 on 12/30/22. The complaint was substantiated as the facility failed to provide required two-person assistance, resulting in the resident falling out of bed and sustaining serious injuries.
Findings
The facility failed to ensure adequate supervision and assistance to prevent accidents for Resident #1, who fell from bed due to CNA #4 providing care alone despite care plans requiring two-person assistance. The fall caused serious injuries including bilateral femur fractures and hematoma. Staff interviews and record reviews confirmed the failure to follow care plans and proper procedures.
Deficiencies (4)
Failed to ensure certified nurse aide (CNA) #4 followed proper procedure while providing cares to Resident #1 and ensure the resident was safe
Failed to implement two-person assistance when providing cares to Resident #1, which was identified as a resident need on their minimum data set (MDS) assessment
Failed to implement a care-planned intervention to provide two-person assistance when providing cares to Resident #1
One of the four staff members audited did not know how to access the care plan and required a demonstration of the process
Report Facts
Residents reviewed for falls: 3
Sample residents: 8
Resident #1 BIMS score: 14
Resident #1 hospital stay duration: 14
Staff members assisting Resident #1 after fall: 4
Interdisciplinary team members: 11
Staff signatures on attendance record: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Named in deficiency for providing care alone to Resident #1 resulting in fall |
| RN #3 | Registered Nurse | Interviewed regarding Resident #1 care and fall incident |
| Medical Director | Medical Director | Interviewed about Resident #1 care requirements and safety |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding MDS assessment and care plan compliance |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Provided facility policy and interviewed about care plan and staffing |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed about staffing and incident details |
| Restorative Certified Nurse Aide #1 | Restorative Certified Nurse Aide (RCNA) | Interviewed about care procedures and resident needs |
| CNA #3 | Certified Nurse Aide | Interviewed about care routines and training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted due to complaints regarding resident-to-resident physical abuse and inadequate dementia care services at the facility.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident abuse by Resident #2 towards Residents #3, #4, #5, and #6. The facility failed to effectively implement supervision and person-centered care approaches to prevent these incidents.
Findings
The facility failed to protect residents from physical abuse by another resident with dementia, resulting in multiple incidents of abuse over several months. The facility also failed to provide adequate dementia care services to meet residents' needs and prevent aggressive behaviors, despite implementing some interventions and staff education.
Deficiencies (2)
Failure to protect residents from physical abuse by Resident #2 in six separate incidents over a four-month period.
Failure to provide adequate dementia care services to meet residents' needs and prevent aggressive behavioral symptoms.
Report Facts
Abuse incidents: 6
Medication dosage: 0.5
Medication dosage: 1
Activity participation: 9.9
Staff training attendance: 17
Frequency of checks: 15
Frequency of checks: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided care for Resident #2 and discussed abuse incidents and interventions. |
| CNA #1 | Certified Nurse Aide | Provided care for Resident #2 and discussed monitoring and interventions. |
| RN #1 | Registered Nurse | Interviewed regarding Resident #2's condition and medication effects. |
| Nursing Home Administrator | Administrator | Provided facility policies, described staff training and process improvement plans. |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, fall prevention, food safety, and COVID-19 testing practices at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure proper activities of daily living care for a resident, inadequate fall prevention practices leading to multiple falls with injuries, improper food storage and handling resulting in unsafe food temperatures and potential cross-contamination, and improper use of PPE and hand hygiene by contracted COVID-19 testing staff.
Deficiencies (4)
Failure to ensure proper activities of daily living care for Resident #231 who was observed calling out for assistance and not being attended to by staff.
Failure to ensure effective and timely fall prevention practices for Residents #19 and #49, resulting in multiple falls, injuries including lacerations, fractures, and skin tears.
Failure to prepare, distribute, and serve food in a sanitary manner including improper cold food storage and serving temperatures, cross-contamination risks, and improper glove use in the kitchen.
Failure to ensure proper use of infection control practices for COVID-19 testing staff including improper glove use, failure to change gloves between residents, and contamination of PPE supplies.
Report Facts
Residents in sample: 30
Falls experienced by Resident #19: 6
Falls experienced by Resident #49: 8
Temperature of cheesecake in walk-in refrigerator: 48
Temperature of cheesecake left unrefrigerated: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Mentioned in relation to failure to respond to Resident #231 calling out for help | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding Resident #231 care and fall prevention | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding Resident #231 care and fall prevention | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding fall prevention and COVID-19 testing staff training |
| Dietary Supervisor (DS) | Dietary Supervisor | Interviewed regarding food safety and infection control practices in dietary |
| Contracted Testing Staff (CST) #1 | Observed and interviewed regarding improper PPE use during COVID-19 testing | |
| Contracted Testing Staff (CST) #2 | Observed and interviewed regarding improper PPE use during COVID-19 testing | |
| Staff Development Coordinator/Infection Preventionist (SDC/IP) | Infection Preventionist | Interviewed regarding training and oversight of contracted testing staff |
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