Legacy at Lamar

A recertification survey with complaint #CO41058 was completed on 1/21/26. Deficiencies were cited. Based on observation and interview, the facility (residence) failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 17 current members (residents).Findings include:The Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outside of the doorway. The specified radius may be determined by the local authority pursuant to section 25-14-207 (2)(a), but must be at least twenty-five feet unless section 25-14.. Based on observations and interviews, the facility (residence) failed to respect a member' s (resident' s) right to privacy and be free of devices that chimed, affecting 17 current residents. Findings include: On 1/21/26, during an environmental tour of the residence, all egress doors were equipped with audible alarms. When opening the side door, a very loud alarm would go off and the residents sitting in the dining room were disturbed by the loud alarm and there were audible sighs of relief when the sound stopped. Staff #2 stated they were not a locked facility. Record review revealed the resident agreements had no mention of the door alarms within the residence. On 1/21/26 at 11:45 a.m... Based on record review and interview the facility (residence) failed to follow their involuntary discharge policy, affecting one former member (resident) (#5). Findings Include:A document titled Steps to Involuntary Discharge, revised July 2024 provided by the residence read in pertinent part that in the case of an involuntary discharge the residence would notify the resident via email, written or oral notification that they would assist the resident with relocation, and that the resident had the right to contact the local ombudsman and/or adult protective services. It contained information detailing that the resident had the right to have assistance in preparing their grievance, that t.. Based on record review and interview, the facility (residence) failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 17 current members (residents).Findings include:On 1/21/26 at approximately 8:30 a.m., the residence' s emergency plan was requested. The residences emergency plan failed to include the following: policies that address a plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids. The emergency plan also failed to include storage and preservation of medications. On 1/26/26 at app.. Based on record review and interview, the facility (residence) failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 17 current members (residents).Findings include:On 1/21/26 at 8:30 a.m., a 72-hour Continuation of Care policy and procedure was requested; however, the residence did not have one included in their emergency policies.On 1/21/26 at approximately 3:00 p.m., the administrator stated she was not aware that a 72-hour plan was included in the residence' s emergency policies. She acknowledged the need for the plan to be in place.

A relicensure survey with complaint #CO41059 was completed on 1/21/26. Deficiencies were cited. Based on interview and record review the residence failed to ensure there was at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization and shall include a skills assessment observed and evaluated by an instructor, affecting 17 current residents. Findings include:On 1/21/26 at 9:30 a.m., staff CPR certifications and the December 2025 and January 2026 staff schedules w.. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 17 current residents.Findings include:The Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or .. Based on observation and interview, the residence failed to ensure it had a fire-resistant waste disposal container in the designated smoking area, affecting 17 current residents. Findings include: On 1/21/26 during an environmental tour at 11:45 a.m., the residence grounds revealed a cigarette wastebasket in the designated smoking area that was not fire-resistant. On 1/21/26 at approximately 3:00 p.m., the administrator stated she was not aware the wastebas.. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 17 current residents.Findings include:On 1/21/26 at approximately 8:30 a.m., the residence' s emergency plan was requested. The residences emergency plan failed to include the following: policies that address a plan that ensures the availability of, or access to, emergency .. Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 17 current residents.Findings include:On 1/21/26 at 8:30 a.m., a 72-hour Continuation of Care policy and procedure was requested; however, the residence did not have one included in their emergency policies.On 1/21/26 at approximately 3:00 p.m., the administrator stated .. Based on record review and interview, the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting 17 current residents.Findings include:On 1/21/26 at 8:30 a.m., the residence' s visitation policy was requested; however, it was not provided.On 1/21/26 at approximately 3:00 p.m., the administrator reported she was not aware the residence n.. Based record review and interview the residence failed to follow their involuntary discharge policy, affecting one former resident (#5). Findings Include:A document titled Steps to Involuntary Discharge, revised July 2024 provided by the residence read in pertinent part that in the case of an involuntary discharge the residence would notify the resident via email, written or oral notification that they would assist the resident with relocation, and that the resid.. 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 7.14.30 The assisted living residence shall maintain a record on a separate sheet for each resident receiving a controlled substance which contains the name of the controlled substance, strength and dosage, ..

A revisit survey was completed on 8/10/23 for all previous deficiencies cited on 1/30/23. 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 relicensure survey was completed on 1/30/23 a deficiency was cited. A change of ownership occured on 1/23/23. Based on record review and interview, the residence failed to notify the department of a change in administrator at least 30 calendar days in advance, affecting 16 current residents.Findings Include:Chapter II regulations governing assisted living residences, part 1.36, defines Letter of Intent as the notification provided to the Department related to an application for a license, to make changes to an existing license, to make changes in services provided by the entity, or for any other business reason the department requests.Review of the department database on 1/29/23 revealed the administrator of record was listed as the administrator since 6/29/2019.On 1/30/23 at 9:05 a.m. a department licensing representative provided an email that read the residence had not provided a letter of intent that notified the department of a change in the administrator prior to the onsite visit on 1/30/23.On 1/30/23 at 1:00 p.m., Staff #1 stated the acting administrator had been at the residence since the beginning of January 2023. The former administrator left at the end of December 2022.On 1/30/23 at 1:00 p.m., Staff #2 stated the acting administrator had been at the residence since the beginning of January 2023. The former administrator left at the end of December 2022.On 1/30/23 at 2:45 p.m., the acting administrator stated she was unaware of the requirement that the depart.. 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 2 and Chapter 7. 18.8 Resident records shall contain, but not be limited to, the following items:(A) Face Sheet;(B) Practitioner order;(C) Individualized resident care plan;18.9 Resident facesheetsThe face sheet shall be updated at least annually and contain the following information:(A) Resident' s full name, including maiden name, if applicable;(B) Resident' s sex, date of birth, and marital status;(C) Resident' s most recent former address;(D) Resident' s medical insurance information and Medicaid number, if applicable;(E) Date of admission and readmission, if applicable;(F) Name, address and contact information for family members, legal representatives, and/or other persons to be notified in case of emergency;(G) Name, address, and contact information for resident' s practitioner and case manager, if applicable;(H) Resident' s primary spoken language and any issues with oral communication;(I) Indication of resident' s religious preference, if any;(J) Resident' s current diagnoses; and(K) Notation of resident' s allergies, if any.