Legacy at Trinidad, the

A relicensure survey with complaint #CO41019 was completed on 1/27/26. Deficiencies were cited. Based on observations and interviews, the residence failed to ensure all interior areas were free from accumulations of extraneous materials and unused or discarded furniture, affecting 24 current residents.Findings Include:An environmental tour of the residence conducted on 1/27/26 at 7:34 a.m. revealed a storage room that contained a large spa tub that was out of order, multiple chairs of various types, several adaptive equipment devices, lamps, and general extraneous materials. There was no method of organization observed.Staff #6 stated in an interview at 2:35 .. Based on observations and interviews, the residence failed to maintain the grounds to protect residents from slopes, holes, and other hazards, affecting 24 current residents.Findings Include:An environmental tour of the exterior of the residence on 1/27/26 at 7:48 a.m. revealed a two to three-inch tripping hazard in the walking path from the front door to the designated smoking area (DSA). The tripping hazard was observed as one slab of the walking path was raised due to settling. Residents were observed going to the DSA from 7:48 a.m. to 4:00 p.m. Additionally, the reside.. Based on records review and interviews, the residence failed to maintain personnel files that contain all required information for three of six sample staff (#1, #2, #3), affecting 24 current residents.Findings Include:The personnel files to include the job description, date of acceptance, initial orientation, and ongoing training transcripts for Staff #1, #2, and #3 were requested from the administrator on 1/27/26 at 9:40 a.m.A review of the personnel files for Staff #1, #2, and #3 revealed incomplete personnel files that did not include job descriptions, date of acceptance, or docu.. Based on records review and interviews, the residence failed to obtain a check of the Colorado Adult Protective Services Data System (CAPS Check) for Staff #2 & #3, affecting 24 current residents.Findings Include:A review of the personnel files for Staff #2 and #3, hired on 7/23/25 and 7/28/25, respectively, revealed no evidence of CAPS Checks for either staff.In an interview on 1/27/26 at 10:45 a.m., the administrator stated that the personnel files were incomplete and did not contain all of the requested information due to the previous administrator failing to ma.. Based on records review and interviews, the residence failed to obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI) before Staff #1 and #2' s hire date, affecting 24 current residents.Findings Include:A review of the personnel files for Staff #1 and #2, both hired on 7/23/25, revealed that the CBI report results were provided to the residence on 7/28/25 and 7/24/25, respectively.In an interview on 1/27/26 at 10:45 a.m., the administrator stated that the personnel files were incomplete and did not contain all of the requeste.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter 7.(U0918) 10.5 Each assisted living residence shall identify its highest potential risk and hold routine drills to facilitate staff and resident response to that risk. There shall be written documentation of such drills.(U1202) 12.20 The assisted living residence shall provide all residents with regular opportunities to participate in structured e..

A recertification survey with complaint #CO41020 was completed on 1/27/26. Deficiencies were cited. Based on records review and interviews, the facility (residence) failed to conduct criminal background checks and comply with CAPS check requirements as required by regulation for three of six sample staff (#1, #2, #3), affecting 24 current residents.Findings Include:A review of the personnel files for Staff #1 and #2, both hired on 7/23/25, revealed that the CBI report results were provided to the residence on 7/28/25 and 7/24/25, respectively.In an interview on 1/27/26 at 10:45 a.m., the administrator stated that the personnel files were incomplete and did not contain all of the requested information due to the previous administrator failing to maintain personnel records.The administrator at 3:26 p.m. acknowledged that Staff #1 and #2' s CBI report results were not received by the previous administrator as required by regulation.A review of the personnel files for Staff #2 and #3, hired on 7/23/25 and 7/28/25, respectively, revealed no evidence of CAPS Checks for either staff.In an interview on 1/27/26 at 10:45 a.m., the administrator sta.. Based on records review and interviews, the facility (residence) failed to maintain records documenting the training of Staff #1, #2, and #3, who provide services to members (residents), affecting 24 current residents.Findings Include:The personnel files to include the job description, date of acceptance, initial orientation, and ongoing training transcripts for Staff #1, #2, and #3 were requested from the administrator on 1/27/26 at 9:40 a.m.A review of the personnel files for Staff #1, #2, and #3 revealed incomplete personnel files that did not include job descriptions, date of acceptance, or documentation of initial orientation and ongoing training.In an interview on 1/27/26 at 10:45 a.m., the administrator stated that the personnel files were incomplete and did not contain all of the requested information due to the previous administrator failing to maintain personnel records.The administrator at 3:26 p.m. agreed that the personnel files for Staff #1, #2, and #3 did not contain any documentation of initial orientation, initial training, or an.. Based on records review and interviews, the residence failed to be an environment that supports member comfort and maintains a home-like quality and feel, as well as provide an outdoor area that is well maintained and apparently equipped for the population served, affecting 24 current residents.Findings Include:An environmental tour of the exterior of the residence on 1/27/26 at 7:48 a.m. revealed a two to three-inch tripping hazard in the walking path from the front door to the designated smoking area (DSA). The tripping hazard was observed as one slab of the walking path was raised due to settling. Residents were observed going to the DSA from 7:48 a.m. to 4:00 p.m. Additionally, the residence had painted the tripping hazard yellow. Observations of the walking paths on either side of the residence, as well as in the rear patio, revealed that they had not been salted or scraped and still had ice and snow collection on them.In an interview with the administrator at 3:26 p.m., she acknowledged that the raised slab in the ..

A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 4/24/24. 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 revisit survey was completed on 2/3/25 for all previous deficiencies cited on 4/24/24. 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 revisit survey was completed on 2/3/25 for all previous deficiencies cited on 4/24/24. 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 complaint revisit was completed on 4/24/24 for all previous deficiencies cited on 11/7/23. The residence is in compliance with all regulations surveyed.The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 11/15/23. 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 #CO35289, #CO35633, and #CO35679, was completed on 4/24/24. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting three of three sample residents (#6-#8). (Cross-reference S1566, S1600)Findings include:1. Residence PolicyThe residence' s medication policy, dated October 2022, read in part the residence administered only medication ordered by the resident ' s practitioner. 2. Re.. Based on observation, record review, and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring staff who provided care to the residents for two of four sample staff (#5, #8) and three of three former staff [#3, #4, and resident care coordinator (RCC)], affecting three of four sample residents (#7-#9) and one former resident (#3). (Cross-reference S0610)Findings includ.. Based on record review and interview, the residence failed to contact the authorized practitioner for clarification of unclear orders and failed to obtain new orders in writing, affecting two sample residents (#8 and #9) and one former resident (#11) who were insulin dependent. (Cross-reference S1530, S1566)1. Residence PolicyThe residence' s medication policy, dated October 2022, read in part that the residence was required to contact the practitioner whe.. Based on record review and interview, the residence failed to ensure a correct name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire for one current sample staff (#5) and two former staff members (#3, #4) affecting 14 current residents and three former residents (#2, #3, #11). (Cross-reference S0612)Findings include:1. Residence PolicyThe residence Empl.. Based on record review and interview, the residence failed to ensure each resident received proper administration, including monitoring of self-administration, affecting one sample resident (#9). (Cross-reference S1566)Findings include:The residence' s medication policy, dated October 2022, read in part that the residence was required to follow practitioner orders and that the residence assisted residents with self-administration, such as monitoring or reminder.. Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting two of three sample residents (#7, #9) and two former residents (#2, #11). (Cross-reference S1522, S1566)1. Residence PolicyThe residence' s medication policy, dated October 2022, read in part that the QMAP .. 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 7.8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall ..

A complaint revisit was completed on 4/24/24 for all previous deficiencies cited on 11/7/23. Deficiencies were cited. Tags Q0628 and Q0630 were not cited in the previous event; however, the deficiencies were included in the previous event' s informational Q9999 tag. Based on observation, record review, and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting three of three current sample participants (residents) (#7-#9) and two former residents (#2, #11).Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, parts: 14.07, requires the residence to ensure that each resident receives proper administration and/or monitoring of medications.14.11, requires the residence to ensure that only medication ordered by an authorized practitioner is prepared for or administered to residents.14.20, requires the residence to contact the authorized practitioner for clarification of anyorders that are incomplete or unclear and obtain new orders in writing.14.29, requires the residence to ensure that each qualified medication administration person (QMAP) accurately documente.. Based on record review and interview, the residence failed to provide protective oversight to all residents (participants) as the residence (facility) failed to conduct a correct name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) for each prospective staff member prior to staff hire for one current sample staff (#5) and two former staff (#3, #4) affecting 14 current residents and three former residents (#2, #3, #11). Findings include:1. Residence PolicyThe residence Employee Credentialing and Hiring policy, dated October 2022, read in part that the residence maintained a safe environment for residents at all times. Therefore, the residence conducted name-based criminal background checks through the CBI on all staff prior to hire, and when the CBI found a criminal background, the administrator completed a documented investigation. The residence' s regional director of operations gave final approval of staff with a criminal history.2. Staff #5A personnel record for Staff #5 read in part t..