LEGACY SUPPORT SERVICES INC

SUMMARY OF FINDINGS:On 4/22/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include; medication changes, assistive devices, and safety equipment. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 8/14/2025 · released to the public 8/21/2025.

SUMMARY OF FINDINGS:On 3/27/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury in the hospital, surgical interventions were declined and the client was started on hospice services. The client’s care plan was updated to reflect safety interventions should they return to include; the client wearing a helmet and proper footwear, rearranging furniture, decluttering their space, assistance with mobility and transfers and reminders to use their walker. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 8/13/2025 · released to the public 8/20/2025.

SUMMARY OF FINDINGS:On 3/25/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) alleged $300.00 was stolen from their purse in their room. During the course of the investigation the healthcare entity conducted a search, and interviews. Twelve individuals who had access to the clients room were interviewed. The police were notified however no assailant was identified. Client (A) was educated to lock their door and staff were to ensure the client's door was locked when leaving. An in-service was conducted on theft and protecting our residents. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 8/14/2025 · released to the public 8/22/2025.

SUMMARY OF FINDINGS:On 3/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. No visible injuries from Client (B) slapping Client (A). Staff #1 witnessed the altercation and stated the slap was not forceful. Staff will redirect the clients away from each other if agitation was seen. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 8/26/2025 · released to the public 9/2/2025.

SUMMARY OF FINDINGS:On 4/8/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. During a training for misappropriation a family member alleged Client (A)’s wedding ring went missing back in December 2024. The police were notified and no assailant was identified. The clients door is consistently locked and all staff were interviewed that were in the clients apartment in the month of December 2024. No staff were aware the client was missing their ring. It is possible the client lost their ring as the family member had taken all other jewelry items out of the facility. It was revealed the family member did ask an ex-staff member on 3/15/25 for a lost and found. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 8/19/2025 · released to the public 8/27/2025.

SUMMARY OF FINDINGS:On 2/6/25, the healthcare entity investigated a reportable event from December 2024. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. Reportedly, staff did not enter a physician’s order into the medication administration record, which resulted in the client not receiving his blood thinner. The family member expressed concerns that the client suffered a medical change due to not receiving his prescribed medication. During the course of the investigation, the healthcare entity conducted a chart audit of physician orders and medications for current clients. The facility identified staff did not follow facility policies or protocols for verifying and processing new physician orders, which contributed to a medication error. Management implemented a new process for staff regarding medication orders and provided education to staff on the process changes. In addition, management implemented a tracking plan for compliance. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 7/1/2025 · released to the public 7/4/2025.

SUMMARY OF FINDINGS:On 8/31/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. The clients were alleged to be in a physical altercation with Client (B) hitting Client (A) in the eye. Client (A) was crying and their left eye was red and swollen. Staff provided treatment and implemented increased safety checks for the client. Staff suspected the assailant was Client (B) due to past interactions with Client (A), however no one witnessed the event. The facility could not determine what happened. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 5/6/2025 · released to the public 5/13/2025.

DESCRIPTION OF OCCURRENCE:On 4/27/24, administrative staff #1 reported to administrative staff #2 that resident (A) had fallen and there were no injuries. However, the administrative staff later reported s/he was concerned of potential neglect due to a staff member documenting differing reports about the fall, and, the positioning of the resident on the floor seemed inconsistent with the way the staff member had described the fall. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardian, ombudsman, physician, and Adult Protective Services. The observation note written by staff #1 read resident (A) was trying to get out of a chair in the dining room and staff #1 took the resident to their room to place them in bed. The resident was trying to get up from the bed and s/he slid to the floor. The resident was assisted up from the floor and vital signs were taken. However, the video surveillance was reviewed and revealed staff #1 had transferred the resident to the bed while the resident was not wearing shoes and staff #1 had failed to use a gait belt. Additionally, staff #1 failed to lock the wheelchair brakes and the wheelchair rolled away and resident (A) fell to the floor. During interview, resident (A) was unable to articulate about the incident due to a diagnosis of dementia. Staff #1 was placed on administrative leave. From the investigation, the facility determined staff #1 had not followed the care plan for resident (A), and the facility policies and procedures for truthful and accurate reporting. Staff #1 was terminated and an in-service was held with all care team members on the appropriate procedures to follow for transfers and accurate reporting. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 11/15/2024 · released to the public 11/25/2024.