Keystone Place at Legacy Ridge Assisted Living

A relicensure survey with complaint #CO40600 and #CO40820 was completed on 9/16/25. Deficiencies were cited. Based on interview and record review the residence failed to ensure the administrator and qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration records affecting 76 current residents. Findings include:On 9/16/25 at 8:00 a.m., the last two quarterly medication a.. Based on interview and record review, the residence failed to establish a fall management program which includeddetailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficitsin strength and balance, affecting two sample residents who sustained injuries from falls (#4, #7). Specifically.. Based on interview and record review, the residence failed to update comprehensive assessments whenever aresident' s condition changed from baseline status, affecting three of nine sample residents (#3, #4 and #9).Findings include: Resident #3 was admitted to the residence on 8/13/23 with a diagnosis of dementia. The most recent assessment for.. Based on observation and interview the residence failed to maintain a physically safe and sanitary environment,affecting 9 current residents within the Chalet. Findings include:On 9/16/25, during an on-site environmental tour, the following was observed:The metal fence surrounding the courtyard in the Chalet was leaning.. Based on observations and interviews, the residence failed to ensure the landscaping was well-maintained toprotect residents from tripping hazards, affecting nine current residents within the Chalet. Findings include: On 9/16/25 at 8:47 a.m., during an environmental tour of the Chalet, the following was observed:The concrete walkway had a five .. Based on record review and interview the residence failed to have at least one staff member onsite at all times who was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 76 current residents.Findings include:On 9/16/25, the residence provided all CPR certificatio.. Based on record review and interview, the residence failed to address in their emergency policies, the storage and preservation of medications or the means of protection and transfer of health information as needed to meet the care needs of residents affecting 76 current residents. Findings Include:On 9/16/25 at 8:00 a.m., the residence emergenc.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting four of eight sample residents (#2, #3, #5, #8).Findings include:Record Review Resident #3 was admitted to the residence on 8/13/23 with a diagnosis of hypothyroidism and unspecified pai.. Based on record review and interview, the residence failed to ensure staff documented, before the end of theirshift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported tothem, affecting two of nine sample residents (#1-#3).Findings include:Resident #1 was admitted to the residence on 9/16/2.. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents and their room assignments, affecting 76 current residents.On 9/16/25 at approximately 7:20 a.m., the residence was asked to provide a resident roster. The Administrative Assistant provided a printed roster which did no.. Based on records review and interviews, the residence failed to develop an involuntary discharge grievance policy that included all required elements affecting 76 current residents.Findings Include:The residence ' s Discharges (Move Out) Voluntary and Involuntary policy, dated 5/12/22 and updated February 2025; failed to include the following r..

A recertification survey with complaint #CO40601 and #CO40819 was completed on 9/16/25. Deficiencies were cited. Based on interview and record review, the residence failed to establish a fall management program which includeddetailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficitsin strength and balance, affecting two sample residents who sustained injuries from falls (#4, #7). Specifically, based on progress notes and incident reports reviewed for Resident #4, who sustained eight falls in a two month peri.. Based on interview and record review, the residence failed to update comprehensive assessments whenever aresident' s condition changed from baseline status, affecting three of nine sample residents (#3, #4 and #9).Findings include: Resident #3 was admitted to the residence on 8/13/23 with a diagnosis of dementia. The most recent assessment for Resident #3 dated 3/14/25 was not updated after a recent change in conditionafter the resident began having increa.. Based on observation and interview the residence failed to maintain a physically safe and sanitary environment,affecting 9 current residents within the Chalet. Findings include:On 9/16/25, during an on-site environmental tour, the following was observed:The metal fence surrounding the courtyard in the Chalet was leaning outward. The fence was in dire need of repairfrom falling over. Multiple residents were observed within the courtyar.. Based on record review and interview the facility (residence) failed to have at least one staff member onsite at all times who was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 76 current members (residents).Findings include:On 9/16/25, the residence provided all CPR certifications for all certified staff; however, no staff were CPR certified on the following dates:9/1.. Based on record review and interview, the facility failed to address in their emergency policies, the storage and preservation of medications or the means of protection and transfer of health information as needed to meet the care needs of members affecting 76 current members. Findings Include:1. Record ReviewOn 9/16/25 at 8:00 a.m., the facility emergency preparedness procedures were requested. On 9/16/25 at approximately 9:00 a.m., a document ti.. Based on record review and interview, the facility failed to comply with authorized practitioner' s orders associated with medication administration, affecting four of eight sample members (#2, #3, #5, #8).Findings include:Record Review Member #3 was admitted to the facility on 8/13/23 with a diagnosis of hypothyroidism and unspecified pain. A written practitioner order dated 10/29/24 directed the facility to administer one 7mg tablet of Levothyroxine once d.. Based on records review and interviews, the facility failed to develop an involuntary discharge grievance policy that included all required elements affecting 76 current members.Findings Include:The facility ' s Discharges (Move Out) Voluntary and Involuntary policy, dated 5/12/22 and updated February 2025; failed to include the following required elements:The grievance can be filed in writing or orally. If orally the facility retains proof through a witness..

A revisit survey was completed on 11/20/24 for all previous deficiencies cited on 7/31/24. The facility is in compliance with all deficiencies that were cited. 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 licensure complaint, prompted by #CO36958, was completed on 7/31/24. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to ensure devices that facilitate a resident' s well-being or independence were used only when there was an order from a practitioner, a practitioner and therapist documented the benefits and hazards associated with the device and information on its appropriate use, the continued use of the device was re-evaluated by both therapist and practitioner at least annually or whenever the resident experiences a significant change in status, and that all of the documentation be retained in the resident ' s care plan affecting four of four sample residents (#5, #6, #9, #10) who used bed canes. (Cross-reference S1110)Findings include: 1. Former Resident #10 was admitted to the residence on 7/16/18 with diagnoses including spinal stenosis and senile degeneration of brain.a. Record Review A verbal practitioner' s order, dated 5/28/24, read that a bed cane was in use at the time of admission; however, the residence was unable to provide a written practiti.. Based on observation, record review, and interview, the residence failed to make available, either directly or indirectly through a resident agreement, personal services including on-going monitoring to meet the resident ' s needs affecting one sample residents (#8) and on former resident (#10).Findings include:1. Resident AgreementThe resident agreement, dated 7/15/23, read in part: "We will work with you, your representative and your health care provider to coordinate a care plan inclusive of your assisted living and personal care service needs (the "Care Plan") that takes into account information from you and your representative, the most recent assessment information and that promotes choice, mobility, independence and safety, details specific needs and preferences, staff tasks to meet those needs, identifies external service providers and care coordination arrangements and identifies formal planned and informal spontaneous engagement opportunities that match your personal choices and needs." 2. Former Resident #10A care p.. 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 7.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident' s representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence' s visitation policy as required by Part 9.2, along with care coordination arrangements;(F) and Identify formal, planned, and informal spontaneous engagement opportunities that match the resident' s personal choices and needs.

A certification complaint, prompted by #CO36959, was completed on 7/31/24. A deficiency was cited. Based on observation, interview, and record review, the facility (residence) failed to identify and outline the participant' s (resident' s) needs and the services and supports to meet those meet those needs in the care plan affecting four of four sample residents (#5, #6, #9, #10) who used bed canes.Findings include: 1. Former Resident #10 was admitted to the residence on 7/16/18 with diagnoses including spinal stenosis and senile degeneration of brain.a. Record Review A verbal practitioner' s order, dated 5/28/24, read that a bed cane was in use at the time of admission; however, the residence was unable to provide a written practitioner' s order dated 7/16/18, the date of the resident' s admission. The residence' s documentation of the investigation of Resident #10' s death, dated 7/29/24, read in part that the resident began using the bed cane in June 2021, contrary to the verbal practitioner' s order.An external service provider (ESP) note, dated 5/7/24, read in part Resident #10 required a transfer pole to improve transfers and reduce fall risk. However, the ESP note failed to provide a therapist evaluation of the use of a bed cane. A comprehensive assessment for Resident #10, dated 6/7/24, read in part that Resident #10 "requires full assistance including physical and verbal assistance with walking needs. Requires hands-on assistance with helping stand up, helping use any walking devices, and helping sit down/lay down." However, the residence did not include the use of a bed cane in the resident ' s assessment. A care plan for for Resident #10, dated 7/1/24, read in part that Resident #10 required hands-on assistance with standing up, using walking devices and sitting down/lay down; however, the residence did not include the use of a bed cane in the resident ' s assessment. An external hospice provider (EHP) progress note, dated 7/1/24, read in part: Resident #10 was found in his bedroom at 5:30 a.m. Staff reported finding Resident #10 ' s body on the floor and his head stuck between the mattress and bed cane; however, no cause of deat..

A complaint revisit was completed on 7/31/24 for all previous deficiencies cited on 12/28/23. The residence is in compliance with all regulations surveyed.The regulations governing Assisted Living Residence were revised and the new regulations were implemented on 7/1/24. 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