LEGACY VILLAGE OF CASTLE PINES LLC

A complaint revisit was completed on 5/12/26 for the previous deficiency cited on 11/24/25. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO41125 and #CO39998, was completed on 11/24/25. A deficiency was cited.

Based on observation, interviews, and record review, the residence failed to protect a resident from verbal, emotional, and physical abuse and intimidation, affecting one of three sample residents (#1). Specifically, Resident #1, who was diagnosed with dementia, was physically assaulted on 11/17/25 by her husband, Former Resident #2. Resident #1 had been observed on 9/30/25 crying and shaking and was very fearful of what Former Resident #2 would do to her. Former Resident #2 began exhibiting increasing signs of paranoia, delusions, and hallucinations since July of the same year. As a result, Adult Protective Services was called, and Resident #1 was moved to another room for two nights so Former Resident #2 could not find her. Care plan dated 10/1/25 indicated the Resident's increase in behavioral disturbances; however, it did not mention the occurrence on 9/30/25 or interventions in place to protect Resident #1 from Former Resident #2 on return to the apartment. Former Resident #2 continued to have increased behaviors and aggression towards Resident #1. On 11/17/25, Former Resident #2 physically assaulted and injured Resident #1. Former Resident #2 was observed on top of Resident #1, holding a pillow over her face, and they were lying next to the bed on the floor. Blood was observed on the pillow and bed sheet. When staff removed the pillow, Former Resident #2 had Resident #1 ' s neck with his right hand, trying to strangle her. Resident #1 sustained deep bruising and skin tears on both wrists, right hand, and arm, requiring her to be transported by ambulance to the emergency room for treatment. Former Resident #2 was taken into police custody and did not return to the residence. 1. Resident #1 was admitted to the facility on 1/31/24 with a diagnosis of dementiaOn 9/30/25, a progress report written at 5:50 p.m. by Staff #4 read in part, Resident #1 pushed her pendant requesting assistance. When the staff arrived, Resident #1 said she wanted to go down for dinner but Former Resident #2 did not want her to go. Former Resident #2 began making unspecified accusations about Resident #1 and her son and asked Resident #1 to leave his room and not come back. Resident #1 was observed to be crying and shaking. Resident #1 told staff she was scared of Former Resident #2 and did not know what to do. Staff was asked to move Resident #1 to another apartment for the night. Staff #4 further reported Resident #1 was very afraid of what Former Resident #2 might do. On 10/1/25, a progress note written by Staff #3 at 4:15 p.m. read in part, Resident #1 was moved from her room for a couple of nights. On the same day at 5:16 p.m., Staff #3 entered a progress note that read in part, after dinner, Resident #1 became emotiona,l stating she wants to go back to her room and knows Former Resident #2 isn ' t going to hurt her. Staff stated that although Former Resident #2 is not physical with her, "he could still be mean to her mental and emotional status." Resident #1 stated "she understood but at the same time she doesn ' t."On 10/31/25 a progress note was entered by Staff #3 read in part, Resident #1 asked staff for assistance with the thermostat in her apartment. When staff turned the heater on, Former Resident #2 proceeded to get upset that someone other than himself had touched the thermostat. Former Resident #2 went to the bathroom and staff could hear him yelling and cursing. On 11/17/25 a progress note was entered by Staff #2 which read in part, Resident #1 pushed her pendant at 3:02 a.m. Staff #2 was helping another resident so got to Resident #1 ' s room around 3:20 a.m. Former Resident #2 was observed laying over Resident #1 holding a pillow over her face. Staff attempted to pull Former Resident #2 off of Resident #1 and take the pillow but could not. Staff called the QMAP for help but before additional help arrived, Former Resident #2 said he is trying tokill Resident #1 and Resident #1 was calling for help. Another staff member came and ripped the pillow away but could not get Former Resident #2 off of Resident #1 and the paramedics were called. Progress note dated 11/17/25 read in part, when staff arrived at 3:20 a.m. Former Resident #2 was holding Resident #1 on the floor pinning Resident #1 by her wrists. Resident #1 was screaming for help and said Former Resident #2 was trying to kill her and she was going to die. When 911 arrived, they were able to pull Former Resident #2 off of Resident #1 and an ambulance arrived to take Resident #1 to the hospital. Former Resident #2 told the officers when they arrived that he was trying to have sex with Resident #1 and she did not want to and that triggered him. Staff further observed that Resident #1 had a "severe skin tear on her right arm and there was blood throughout the room."On 11/17/25 an ambulance report read in part , Resident #1 was complaining of bilateral arm pain, left knee pain, and neck discomfort. The cause of injury was listed as assault by bodily force, and she was transported to the hospital for treatment. Return ambulance report dated 11/20/25 documented Resident # 1 was hospitalized forassault/strangulation, skin tears on both forearms, bruising on upper legs, and an abrasion near leftClavicle. On 11/20/25, Resident #1 was observed to have closed wounds on her right hand, right arm and bruising on both arms. 2. Former Resident #2 was admitted to the facility on 1/31/25 with diagnoses including intestinal cystitis and arthritis. The care plan dated 1/31/23 did not mention Former Resident #2 was showing signs of dementia, paranoia or aggressive behavior at that time. On 10/1/25 a progress note was entered at 1:16 p.m. by the administrator that read in part, staff reported the prior evening that Former Resident #2 was extremely agitated through the night and intruded into other resident ' s apartments looking for Resident #1. The administrator met with Former Resident #2 who began making "delusional statements". The administrator further reported Former Resident #2 was not able to be redirected or reoriented and his delusions and paranoia had significantly increased over the last week. On 10/1/25 a progress note was entered by the administrator at 3:49 p.m. which read in part, Adult Protection Services (APS) was notified to report Former Resident #2 ' s increasing delusions and paranoia. APS advised the administrator to have a medical provider write a letter stating Former Resident #2 is incompetent and in the meantime, if/when Former Resident #2 has increased behaviors, such as hard to redirect or disruptive to other residents, to call the Sheriff and with the assistance of the Critical Response Team (CRT), have Former Resident #2 transferred to the emergency room for psychiatric evaluation and treatment. Former Resident #2 ' s care plan was updated to reflect a history of behaviors including paranoia, delusions, hallucinations, irritability, aggression, wandering, and verbal abuse. Care plan dated 10/1/25 documented the following: Resident # 2 has a history and current behaviors including Paranoia, delusions, hallucinations, irritability, aggression and wandering. He can be verbally abusive and accusatory. If he is experiencing any or all of these things, attempt to redirect and de-escalate the situation. Do not tell him he is wrong or minimize his feelings. Notify nursing and or senior management immediately for support. However, the care plan did not indicate the event on 9/30/25 that is documented in Resident #1's progress notes and how they will keep her safe after returning to their shared apartment. On 10/2/25 Former Resident #2 ' s care provider evaluated Former Resident #2 for dementia. The care provider ' s note read in part, Former Resident #2 has a history of dementia for which he experiences paranoia, delusions and more recently hallucinations. Former Resident #2 was previously on sertraline; however, he was experiencing more paranoia and delusions, and thus, he was switched to seroquel. The care provider further noted that Former Resident #2 was not experiencing any behaviors while on seroquel but Former Resident #2 stopped taking it as he did not like the way it made him feel. Resident #2 had declined further and had become disruptive to himself, his wife, and other residents in the community. Former Resident #2 was diagnosed with mild vascular dementia with anxiety and cerebrovascular disease. On 10/5/25 a progress note entered by Staff #4 read in part, Former Resident #2 would not allow Resident #1 to go down to dinner and was observed standing in front of Resident #1 and would not let her go. Eventually, Former Resident #2 allowed staff to walk Resident #1 to the dining room. On 10/17/25 a progress note was entered by Staff #3 who said Resident #1 pushed her pendant for help/escort to lunch. Former Resident #2 said he was not hungry. Staff stated that was okay but that Resident #1 was going for lunch. Former Resident #2 said if she goes to lunch to not come back and to go to her secret room. It was then reported Former Resident #2 came out of his room hollering and yelling at other residents, wait staff, concierge and care staff, which was reported to the nurse and administrator. On 11/2/25 a progress note entered by the wellness nurse said she was approached by another resident and his wife stating Former Resident #2 had spoken aggressively to them and accused him of being a "hacker". The resident and his wife were both upset by this accusation. On 11/17/25 an incident report was entered which read in part, Resident #1 pushed her pendant at 3:02 a.m. Staff #2 was helping another resident so got to Resident #1 ' s room around 3:20 a.m. Former Resident #2 was observed on top of Resident #1 holding a pillow over her face and they were lying next to the bed on the floor. Blood was observed on the pillow and bed sheet. When staff removed the pillow, Former Resident #2 circled Resident #1 ' s neck with his right hand trying to strangle her. Resident #1 was screaming that Former Resident #2 was hurting her and trying to kill her. 911 was called and when the sheriff arrived, they were able to pull Former Resident #2 off of Resident #1. Resident #1 was observed to have blood on her arms and clothing. Both residents were taken by ambulance to two different hospitals for evaluation. Following this incident, Former Resident #2 was taken into police custody. Interviews:On 11/20/25 at approximately 4:00 p.m. an interview was conducted with Staff #2. Staff #2 stated that after the 9/30/25 incident when Resident #1 was moved to another room away from Former Resident #2, she was instructed to contact 911 if Former Resident #2 acted out. When asked if Staff #2 understood what specific behaviors Former Resident #2 would need to exhibit to necessitate calling 911, Staff #2 said she was not sure. On 11/20/25 at approximately 11:30 a.m. an interview was conducted with Former Resident #2 ' s care provider who stated the facility reported to him that they began seeing an increase in Former Resident #2 ' s agitation and paranoia approximately 3 months ago. Former Resident #2 was prescribed seroquel to manage his paranoia but Former Resident #2 stopped taking it because he did not like the way it made him feel. Former Resident #2 care provider further stated that he and the administrator felt "stuck" since Former Resident #2 was refusing medical interventions and refused to take part in a more comprehensive neuropsych examination. On 11/20/25 at approximately 3:00 p.m. an interview with the administrator revealed that on 10/2/25, a meeting was held with Resident #1, Former Resident #2 and their POA to discuss the events on 9/30/25. The administrator stated during this meeting, Resident #1 expressed no fear of Former Resident #2 and wished to move back to her apartment with Former Resident #2. The administrator also stated that Former Resident #2 told her he had no intention of harming Resident #1 and since the POA agreed, the administrator allowed Resident #1 to return to her apartment with Former Resident #2. On 11/20/25 at approximately 4:00 p.m. a second interview was held with the administrator, who stated she contacted APS to report Former Resident #2 ' s increasing delusions and paranoia. The administrator said APS advised them to obtain an incapacitation letter to appoint a POA but until then, she felt "truly stuck" and believed they had to wait for another incident to occur involving Former Resident #2 before they could relocate him.

A relicensure survey and complaint revisit was completed on 4/30/25 for all previous deficiencies cited on 9/26/24. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event OSKZ12 were cited prior to the regulation revision that was implemented on 3/15/25.

A relicensure survey with complaint #CO00037360 was completed on 9/26/24. Deficiencies were cited.

12.2.1 Infectious Disease Mitigation, Vaccine, and Treatment Plans (A) All facilities licensed under this chapter shall establish maintain, and implement an infectious disease mitigation, vaccine and treatment plan. The plan must demonstrate prevention of and responsiveness to communicable diseases that are or may become present in the individual facility setting. The plan may include testing, vaccination, and treatment. This plan shall address, at a minimum, the following: (1) administration, and tracking and reporting of the vaccination status of staff and, if applicable, residents on an ongoing basis; (2) The name and location of the infectious disease vaccine and treatment provider(s) that will be used by the facility to facilitate administration of vaccines and treatment; (3) How the facility will assess and address the vaccination of new staff and, if applicable, residents. Based on record review and interview, the residence failed to establish, maintain, and implement infectious disease mitigation, vaccine and treatment plans, affecting 108 current residents. Findings include:On 9/25/24 at 12:18 p.m., the residence's infectious disease mitigation, vaccine, and treatment plans were requested but not provided. On 9/26/24 at 1:00 p.m., the health and wellness director and the administrator acknowledged that the residence did not have an infectious disease mitigation, vaccine, and treatment plans.

12.2.2 Infection Control Officer (A) Applicability (1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated: (a) Assisted Living Residences; (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following: (1) Completing an infection prevention and control training from a nationally recognized provider or the Department's training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type; (a) Infection Control Officers at nursing care facilities and intermediate care facilities for persons with intellectual and developmental disabilities shall complete at least nineteen (19) hours of initial training. (b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training. Based on record review and interview, the residence failed to assign at least one staff member responsible for the site management of the residence's infection prevention and control program and training, affecting 108 current residents. Findings include:On 9/25/24 at 12:18 p.m., the residence's completed training certificates for the infection prevention and control officer were requested but not provided. On 9/26/24 at 1:00 p.m., the health and wellness director and the administrator acknowledged that the residence did not have a designated infection control officer; therefore the residence had not completed training from a nationally recognized provider for the infectious diseases mitigation program.

Based on record review and interview, the residence's staff failed to promptly respond to an emergency affecting one former resident (#15). Findings include:1. Personnel Record ReviewA personnel file for Staff #5 revealed a hire date of 6/21/24. A Notice of Disciplinary Action for Staff #5, dated 8/27/24, read in part: On 8/11/24, Staff #5 was called for assistance in Resident #1's room. Staff discovered the resident did not have use of the left side of their body, could not sleep, could not eat, and had slurred speech. At 8:00 a.m., Staff #5 failed to call 911, and again at 11:00 a.m., Staff #5 failed to recognize the signs and symptoms of a stroke. A personnel file for Former Staff #7 revealed a hire date of 10/3/23. A Notice of Disciplinary Action for Former Staff #7, dated 8/27/24, read in part: on 8/11/24 Former Staff #7 was called for assistance in a resident's room. Staff discovered that the resident did not have use of the left side of their body, could not sleep, could not eat, and had slurred speech. At 8:00 a.m., Former Staff #7 failed to call 911, and again at 11:00 a.m., Former Staff #7 failed to recognize the signs and symptoms of a stroke. 2. Resident Record ReviewFormer Resident #15 was admitted to the residence on 9/23/22 with a diagnosis of dementia. A progress note, dated 8/12/24, read in part that on 8/11/24 Former Resident #15 was found at 8:00 a.m. by staff. Former Resident #15 stated she fell the night before. Former Resident #15 could not bear weight and could not sit up. She had normal speech and responses at the time. Staff got the resident up for the day and attempted to serve breakfast. At 11:00 a.m., Former Resident #15 contacted her family member to take her to the hospital. When Former Resident #1's family member arrived, she contacted 911. Former Resident #15 left the residence by ambulance at approximately 12:00 p.m., which was approximately four hours after staff recognized drastic changes in the former resident's baseline status. A progress note, dated 8/28/24, read in part: The residence was informed that Former Resident #15 had sustained a stroke and was not returning to the residence. 3. InterviewsOn 9/25/24 at 1:30 p.m., the administrator stated she conducted an investigation after being contacted by Former Resident #1's family member and discovered Staff #5 and Former Staff #7 failed to contact 911 and were trained on recognizing the signs and symptoms of a stroke and what to do. On 9/25/24 at 2:45 p.m., the assisted living director stated an incident report was not completed for this event because staff failed to contact 911; it was Former Resident #15's family member who contacted 911. On 9/25/24 at 1:15 p.m., Former Resident #15's family member stated Former Resident #15 called her on the phone on 8/11/24 at approximately 10:30 a.m.; at that time the resident's speech was slurred, and she explained she did not feel well. The family member then spoke with the staff, who were in the room at the time the former resident called her, stating she would meet them at the emergency department (ED). The family member stated she instructed Resident #15 to hang up the phone and that the staff would help her. The family member stated that when she arrived at the residence at approximately 11:15 a.m., to get information to provide the staff at the ED, she found Resident #15 in her bed alone, her left arm curled to her chest, her face drooping, and she was unable to move her left side. The family member then called 911 and Former Resident #15 was transported to the ED by ambulance at approximately 12:00 p.m.

Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy, affecting 107 current residents. Findings include:On 9/25/24 at 9:13 a.m., the residence's discharge policy dated 2018, read in part: "1. The community may discharge or transfer a resident for one of the following reasons: a. The community is no longer able to meet the resident ' s needs because the resident poses a threat to the health or safety of self or others, or the community is not able to provide required medical treatment or services; b. Failure to pay fees or charges as required by the Service Agreement; c. The resident fails to comply with service agreement, written policies, or rules of the community; d. The resident wishes to transfer; or e. The community ceases to operate. 2. Prior to transferring or discharging a resident, the community shall serve a transfer or discharge notice upon the resident and the responsible person. The notice shall:a. Be hand-delivered or sent by certified mail; b. Be made at least thirty (30) days before the day on which the community plans to transfer or discharge the resident (except as noted below); c. Be in writing with a copy placed in the resident file; d. Be phrased in a manner and in a language the resident can understand; e. Detail the reasons for transfer or discharge; f. State the effective date of transfer or discharge; g. Inform the resident of their right to call advocates; h. Contain the following information: i. The name, mailing address, and telephone number of the State Long Term Care Ombudsman 3. The community may discharge or transfer a resident without notice if: a. The resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals living in the community; or b. The resident ' s urgent medical or health needs require immediate transfer to another health care institution. c. The responsible party will be notified as soon as possible. 4. The community shall mail a copy of the move-out notice to the ombudsman within 5 days of providing the written notice to the resident or responsible party. 5. The community may not discharge a resident for the sole reason that the resident ' s legal representative requests to install or operate a monitoring device in the individual ' s room. 6. The resident shall not terminate an agreement without providing the community with a 30-day written notice. 7. Upon issuing a notice of termination, the community shall provide the resident and responsible person a copy of the resident ' s service plan, copy of immunization records, phone numbers and addresses of the local Long-Term Care Ombudsman. 8. The community shall provide sufficient preparation and orientation to a resident to ensure a safe and orderly transfer or discharge from the community. 9. The community may collect storage fees equal to the daily rate from the date of the termination until personal property is removed from the community. 10. In the event that the resident has not vacated by the date indicated on the termination notice, the resident or responsible person will be in violation of this agreement and any daily charges or costs incurred by the community will be billed to the resident or responsible person. 11. Within thirty (30) days after the termination, the community shall give the resident or responsible person a final statement of the resident ' s account. 13. Upon termination of the agreement, any monthly fees paid for time following the termination will be refunded as follows: Refund will be calculated establishing the daily rate and then multiplied by the number of days remaining/unused."The policy failed to include the following required elements:(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence.(D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or(2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence.(a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation.(D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation."(F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.(G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part.(H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending.(I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board,(2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and(3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process."On 9/26/24 at 1:00 p.m., the administrator acknowledged the residence had not updated their discharge policy to reflect the most recent regulation changes.

Based on record review and interview, the residence failed to ensure its emergency policies and procedures included instructions on when and how to evacuate the premises; a pre-determined means of communicating with residents, families, staff, and others; a plan to ensure the availability of emergency power for essential functions and all resident-required medical devices; the storage and preservation of medications; the assignment of specific tasks and responsibilities to the staff member on each shift; the protection and transfer of health information; and finally, written agreements with other organizations to assist with the relocation of residents, affecting 107 current residents. Findings include:The residence's Emergency Fire Evacuation book, dated 7/26/24, did not contain the following: instructions for staff to know when and how they should evacuate the premises, a predetermined evacuation plan for communication with residents, their families, staff, and other stakeholders, a plan to ensure the availability of emergency power for essential functions and all resident-required medical devices, a plan for the storage and preservation of medications, assignment of specific tasks and responsibilities to the staff members on each shift, a plan to ensure the protection and transfer of health information, nor written agreements with other organizations to assist the residence with the relocation of the residents should an evacuation be required. On 9/26/24 at 12:30 p.m., the administrator acknowledged the residence needed to add the required elements to their emergency preparedness plan. She stated that she recently updated the plan but had not yet had time to complete all of the updates. The administrator added that the residence did have a generator but was unaware she was required to include this information in the plan. She also stated that they had a verbal agreement with another local residence but did not have a written agreement.

Based on record review and interview, the residence failed to obtain a practitioner's assessment when a resident experienced a significant change in their baseline status, affecting one former resident (#15). Findings include:Former Resident #15 was admitted to the residence on 9/23/22 with a diagnosis of dementia. A current care plan for Former Resident #15, dated 3/25/24, read in part that Former Resident #15 could ambulate safely with the use of a walker to help with balance. A progress note, dated 8/12/24, read in part that on 8/11/24, staff found Former Resident #15 at 8:00 a.m., unable to bear weight and could not sit up due to weakness of the left side extremities. On 9/25/24 at 1:30 p.m., the administrator stated that through investigation she discovered Staff #5 and Former Staff #7 failed to contact any medical practitioners after discovering Former Resident #15 had sustained a change in baseline status. On 9/25/24 at 1:15 p.m., Former Resident #15's family member stated she spoke with Former Resident #15 on the phone, on 8/11/24 at approximately 10:30 a.m., at that time the resident's speech was slurred, and explained she did not feel well. The family member explained she was under the assumption after getting off the phone that the staff would be contacting medical services. She stated that at approximately 11:15 a.m., when she arrived at the residence, she discovered staff had not contacted any medical services for an assessment. The family member stated she contacted 911 after recognizing the signs and symptoms of a stroke.

Based on record review and interview, the residence failed to notify a resident's representative whenever the resident experienced a significant change in their baseline status, affecting one former resident (#15). Findings include:Former Resident #15 was admitted to the residence, on 9/23/22, with a diagnosis of dementia. A current care plan for Former Resident #1, dated 3/25/24, read in part that Former Resident #15 could ambulate safely with the use of a walker to help with balance. A progress note, dated 8/12/24, read in part that on 8/11/24, staff found Former Resident #15 at 8:00 a.m., unable to bear weight and could not sit up due to weakness of the left side extremities. There was no documentation indicating staff informed Former Resident #15's legal representative of the significant change from baseline status. On 9/25/24 at 1:30 p.m., the administrator stated staff did not inform her of this situation at the time of the event. She investigated after being contacted by Former Resident #1's family member the following business day. On 9/25/24 at 1:15 p.m., Former Resident #1's family member stated she spoke with Former Resident #15 on the phone on 8/11/24 at approximately 10:30 a.m., because the former resident contacted her. The family member stated that at that time, the former resident's speech was slurred and she explained she did not feel well. She added that a staff member was in the room during the phone call and only spoke to the family member after Former Resident #15 notified her, which was approximately four hours after they noticed a significant change in the former resident's baseline status.

Based on record review and interview the residence failed to detail in each resident's care plan the individualized approaches necessary to address fall risk, affecting two of 15 sample residents (#10 and #13). Specifically, from 8/12/24 through 9/11/24, Resident #10 experienced seven falls within 30 days during which the residence failed to update the care plan for Resident #10 to include individualized approaches necessary to address fall risks. On 8/24/24, Resident #10 was transported to the emergency department (ED) due to a fall. On 9/10/24, Resident #10 again had a fall which resulted in a head injury to the back side of the head and was admitted to the hospital. Findings include:1. Reference and Residence Policya. Chapter 7 regulations governing assisted living residences, requires in part 12.15 that, "The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: B) Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment ..." b. The residence's Fall Management Program policy, undated, read in part: The residence would implement a proactive approach to addressing falls. The residence would regularly evaluate the resident's fall risk and implement individualized strategies to prevent falls. Residents identified to have a new fall pattern or new fall risks would have an assessment to update the service plan with fall management interventions. 2. Record ReviewResident #10 was admitted to the residence on 9/27/23 with a diagnosis of dementia with behavioral disturbance. A current care plan for Resident #10, dated 3/25/24, read in part: Resident #10 had a history of falls; staff were directed to be aware and monitor for safety. Resident #10 was very active and staff were to help direct her to be safe when ambulating. Resident #10 independently ambulated. A progress note, dated 8/12/24, read in part: the staff found Resident #10 on the floor, sitting upright. A progress note, dated 8/23/24, read in part: Resident #10 had a fall in her room, she fell backward while opening her dresser. She had a minor abrasion on her right elbow. A progress note, dated 8/24/24, read in part: Resident #10 returned to the residence from the hospital due to a fall, at approximately 6:10 p.m., the same day. A fall assessment, dated 8/25/24, read in part: Resident #10 fell in the dining room during lunch, no injuries were noted. A progress note, dated 8/29/24, read in part: Resident #10 was sitting on the floor in front of her bed. She denied any pain or injuries. A progress note, dated 9/10/24, read in part: Resident #10 fell in the dining room while listening to live music. She stood up and turned to the right, falling backward and hitting the back of her head on a chair. The injury was heavily bleeding and she was taken to the hospital. A progress note, dated 9/11/24, read in part: Resident #10 fell in the dining area and had a skin tear on her elbow. 3. InterviewsOn 9/26/24 at 12:15 p.m., the administrator stated that the residence was behind on updating the resident care plans. She added they were working on falls and putting measures in place to mitigate fall risk but have not documented this correctly. 4. Additionally, the residence failed to detail in the care plan for Resident #13 any individualized approaches necessary to address fall risk after Resident #13 displayed a similar pattern of falls.

Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records list, controlled substance list, medication error reports and medication disposal records, affecting 107 current residents. Findings include:On 9/25/24 at 9:13 a.m. the residence's last two quarterly medication administration record audits were requested but not provided. On 9/25/24 at 10:50 a.m. the administrator acknowledged that the residence had not completed or documented quarterly medication administration record audits since December 2023.

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, their room assignments, and emergency contact information, along with a facility diagram showing room locations. 18.8 Resident records shall contain, but not be limited to, the following items: (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.

A revisit survey was completed on 5/7/24 for all previous deficiencies cited on 2/21/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 5/2/24 for all previous deficiencies cited on 2/10/23. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO31886, #CO33753, #CO33756, and #CO34518, was completed on 2/21/24. A deficiency was cited.

Based on record review and interview, the residence failed to provide nourishing meal substitutes and between-meal snacks, affecting 32 current residents residing in the secure environment. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part that the residence included in the monthly fee: three meals per day with snacks available. Furthermore, the agreement read that in the secure environment, the residence provided three meals per day and a daily snack upon request. 2. InterviewsOn 2/21/24 at 12:31 p.m., the wellness director stated that the residence offered snacks that were not nourishing or nutritious. She stated she would like it if the residence's kitchen supplied the secure environment with pre-made, wrapped, and dated turkey or peanut butter and jelly sandwiches so that the staff could offer nourishing and nutritious options between dinner and breakfast. On 2/21/24 at 2:13 p.m., the memory care director (MCD) stated that the dinner cart was transported from the kitchen to the secure environment daily at approximately 4:00 p.m., adding that the residents ate dinner shortly thereafter. The MCD stated that the residence's kitchen provided no nourishing snacks to offer the residents after dinner and throughout the night, adding that breakfast (the next time food was offered) was served between 6:30 and 7:00 a.m. (approximately 15 hours after dinner service). The MCD stated that the only snacks the staff in the secure environment could offer residents during this time was pudding, jello, or apple sauce. On 2/21/24 at 3:16 p.m., the administrator stated she was not aware of what food supplies the residence's kitchen was providing to the secure environment. She stated that she did not consider pudding, jello, or apple sauce nourishing or balanced snacks. The administrator acknowledged that the MCD stated that the answer was "no" when she asked the residence's kitchen staff for nourishing foods to offer the residents in the secure environment. She added that she, along with the MCD, WD, and dining services director needed to revisit the residence's plan for supplying nourishing foods to the secure environment for residents who want to eat outside of scheduled meal service times.

A licensure complaint, prompted by #CO29961, was completed on 2/10/23. A deficiency was cited.

Based on record review and interview, the residence failed to ensure that no medication was administered by a qualified medication administration person (QMAP) on a pro re nata (PRN) or "as needed" basis, affecting one of four sample residents (#3). Findings include:A written practitioner's order, dated 6/1/22, directed the residence to administer Ativan 0.5 mg once in the morning and once as needed for anxiety to be assessed by the residence's nurse. The February 2023 medication administration record (MAR) read the residence administered Ativan 0.5 mg as needed on 2/4 and 2/5/23 for anxiety and on 2/6/23 for pain. A progress note, dated 2/5/23, read in part that the resident had pain and anxiety once or twice and Ativan was administered. A progress note, dated 2/6/23, read in part that Resident #3 was confused, panicked, and agitated. PRN medication was administered. On 2/10/23 at approximately 11:55 a.m., Staff #1 acknowledged that a QMAP administered Ativan PRN to Resident #3 each day from 2/4 to 2/6/23. She stated the resident had not ever asked her for anxiety medication, adding that she was unable to ask for it. Staff #1 stated that she had administered Ativan to Resident #3 after sending an electronic message and telephoning the WD because the resident was hitting walls and her bed, and no other behavioral interventions were working. On 2/10/23 at approximately 12:03 p.m., the wellness director (WD) stated residents were required to request PRN medications. She stated if the residents were unable to request the medication, the QMAP telephoned and/or video-called her or an external service provider nurse to tell them what they were seeing and hearing. The WD stated that following the phone call or telehealth visit, she instructed the QMAP to administer Ativan, and the QMAP documented it as such on the MAR for Resident #3. On 2/10/23 at 12:45 p.m., the administrator stated that if the written practitioner's order did not specify the parameters for administering a PRN medication, the QMAP called either the WD or the administrator on the telephone, who directed the QMAP to administer the PRN medication.