Legacy at Sterling

A revisit survey was completed on 4/15/26 for all previous deficiencies cited on 12/11/25. 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 #CO39432 was completed on 12/11/25. A deficiency was cited. Based on record review and interview, the residence failed to ensure each staff, including contracted staff, had completed training specific to recognizing behavioral expression and management techniques and dementia prior to providing resident care for one (Staff #2) of five sampled staff members, affecting 26 current residents. Findings include:1. Record reviewPersonnel files for Staff #2 contained no documentation showing that the residence provided completed training specific to recognizing behavioral expression and management techniques, or dementia related training prior to Staff #2 providing care or services to residents.Staff #2 was hired on 9/21/25 and has provided care to residents since 9/25/25.2. InterviewsOn 12/11/25 at approximately 11:20 a.m., Staff #2 stated that she had not received any formal training or orientation on recognizing behavioral expression and management techniques or dementia related training prior to beginning her duties. Staff #2 went on to state her training from the residence consisted of shadowing other staff and learning from them what to do, in addition to the training she received at a previous job. On 12/11/25 at 4:46 p.m., the administrator (AD) acknowledged Staff #2 did not receive formal training from the residence on recognizing behavioral expression and management techniques, nor did Staff #2 receive deme.. 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 7.11.5 The assisted living residence shall review its resident agreements annually and update or amendthem as necessary. Amendments to the resident agreement shall also be signed and dated byboth parties.(A) When a change of ownership occurs, the new owner shall either acknowledge and agreeto the terms of each existing resident agreement or establish a new agreement with eachResident.11.6 The written resident agreement shall specify the understanding between the parties concerning,at a minimum, the following items:(A) Assisted living residence charges, refunds and deposit policies;(B) The general type of services and activities provided and not provided by the assistedliving residence and those which the assisted living residence will assist the resident inobtaining;(C) A list of specific assisted living residence services included for the agreed upon rates andcharges, along with a list of all available optional services and the specified charge foreach;(D) The amount of any fee to hold a place for the resident in the assisted living residencewhile the resident is absent from the assisted living residence and the ..

A certification complaint , prompted by #CO39434, was completed on 12/11/25. No deficiencies were cited. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10, Chapter 8.70006.8.7001.B.3.a.i-1Written agreement must:Provide substantially the same terms for all individuals;Specify the duration of the agreement;Specify rent or room-and-board charges;Specify refund policies for a absence, hospitalization, voluntary or involuntary move to another setting, or death; Be signed by all parties, including the individual or, Guardian or other Legally Authorized Representative within their authority.Provide the same responsibilities/protections from eviction that tenants have under the landlord/tenant law;Specify the individual will occupy a particular room/unit;Explain the conditions under which they may be asked to move/leave;Provide a dispute/appeal process, seek review by a neutral decisionmaker for notice they must move or leave, or tell individuals where to easily find an explanation of such a process, stating this in any notice to move or leave;

A revisit survey was completed on 4/26/24 for all previous deficiencies cited on 1/18/24. 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 relicensure survey with complaint #CO34463 was completed on 1/18/24. Deficiencies were cited Based on observation and interview, the residence failed to place in a visible on-site location the residence' s internal process for raising and addressing grievances and complaints, along with full contact information for required agencies, affecting 24 current residents. Findings include:On 1/17/24 from 7:45 a.m. to 9:09 a.m., there was no process for addressing grievances and complaints placed in a visual onsite location along with full contact informatio.. Based on observation, interviews and record reviews, the residence failed to evaluate its resident engagement program at least every three months or offer residents relevant and well-received engagement activities, affecting 24 current residents.Findings include:1. ObservationsOn 1/17-1/18/24, residents were observed sitting alone or with others in the lobby, in the dining room and in the residence' s hallways or wandering around the residence' s hallways, .. Based on record review and interview the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring two of two sample staff (#1, #2) who provided direct care to at-risk residents, affecting 24 current residents.Findings include:1. References a. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs.. Based on record review and interview, the residence failed to ensure a name-based criminal history record check that was conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective employee prior to staff hire, for two of two sample staff (#1-#2), affecting 24 current residents.Findings include: Review of the personnel file for Staff #1 revealed a hire date of 3/2/23; however, the file contained no evidence a name-based cri.. Based on record review and interview, the residence failed to have a written policy that provided for effective control and eradication of insects, rodents, and other pests, affecting 24 current residents. Findings include: On 1/17/24 at 8:39 a.m., the residence' s environmental pest control policy and procedure was requested; however, was not provided. On 1/17/24 at 3:51 p.m., the assistant administrator confirmed that the residence did not have a writt.. Based on record review and interview, the residence failed to include written documentation regarding orientation and training, for two of two sample staff (#1-#2), affecting 24 current residents.Findings include:The residence' s personnel file for Staff #1 revealed no documentation of orientation and training. The residence' s personnel file for Staff #2 revealed no documentation of orientation and training. On 1/18/24 at 10:40 a.m., the assistant administrato.. 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 7.13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. 13.3 The assisted living residence shall establish ..

A recertification survey was completed on 1/18/24. No deficiencies cited. 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 10 CCR 2505-10 8.400.8.495.6(H)(2) Alternative Care Facility Providers shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations.Chapter VII regulations governing assisted living residences, part 14.27, requires that the assisted living residence shall be responsible for complying with no stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident' s full name.

A revisit survey was completed on 12/15/2023 for all previous deficiencies cited on 5/3/2023. 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 revisit survey was completed on 12/15/2023 for all previous deficiencies cited on 5/3/2023. 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