Legacy Village of Castle Pines LLC

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 Residen..

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 indi.. 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 Co.. A relicensure survey with complaint #CO00037360 was completed on 9/26/24. Deficiencies were cited. 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 u.. 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 reas.. 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 reside.. 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 Forme.. 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 .. 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' .. 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.. 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 o..

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 ..

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 eith..