Legend of Colorado Springs

A revisit survey was completed on 3/18/25 for all previous deficiencies cited on 10/15/24. 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 #CO33726 was completed on 10/15/24. Deficiencies were cited. Based on observation and interview the residence failed to place in a visible location an up-to-date list of all staff with current certification in first aid or CPR so that the information is readily available to all staff at all times affecting 94 current residentsFindings include:On 10/16/24 from 7:30 a.m. to 5:00 p.m., there was no posted list of CPR certified staff throughout the residence. On 10/16/24 at 5:00 p.m., the residence director stated the residence did not have a posted list of CPR certified staff. Based on observation and interview, the residence failed to ensure each resident received proper administration and monitoring of medications, affecting two (#2, #3) sample residents.Findings include1. ReferencesThe residence Medication Administration policy, dated 4/30/19. read in part, the person responsible for administering medications would observe the resident swallowing the medication. 2. Observation On 10/15/24 at 9:45 a.m., an oval shaped green pill with the engraving V75 was found on the ground approximately three feet across from the medication cart .. Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy which included all required elements, affecting 94 current residents.Findings include:The residence' s resident agreement part D, "Involuntary Termination of Agreement", failed to include the following required elements:1. Identification of the individual at the residence designated to receive grievances related to involuntary discharge.2. Explanation that residents, or others filing on their behalf, must have the ability to receive assistance in.. Based on record review and interview the residence failed to have a readily available roster of current residents with their emergency contact information, affecting 94 current residents.Findings include:On 10/15/24 at 8:55 a.m., the residence' s resident roster was requested.On 10/15/24 at approximately 9:30 a.m., the residence' s resident roster was provided. However, the resident roster did not include the residents' emergency contact information.On 10/15/24 at 1:50 p.m., Staff #6 stated the emergency resident roster was located behind the front desk. She further stated the r.. Based on record review and interview the residence failed to provide accurate and truthful information to the Department during an inspection and investigation, affecting 94 current residents.Findings include:1. Record ReviewOn 10/15/24 at approximately 1:00 p.m., evidence obtained during the onsite investigation revealed that the assistant health care director (AHCD) failed to provide accurate and truthful information about Resident #5 ' s care plans. The care plan revealed that she back dated the care plans to reflect that she reviewed and signed them on 6/.. 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 7.7.13 Personnel files for current employees and volunteers shall be readily available onsite for Department review. Each personnel file shall include, but not be limited to, written documentation regarding the following items: (D) Orientation and training, including first aid and CPR certification, i..

A licensure complaint, prompted by #CO28609, #CO29765, and #CO30884, was completed on 5/18/23. Deficiencies were cited. Based on record review and interview, the residence failed to provide fall management education and materials to residents and family members, affecting one sample resident (#1) and one former resident (#5).Findings include:1. Residence PolicyThe residence' s Fall Risk Assessment Policy, dated 8/20/22, read in part: The residence' s fall program included providing fall management education and materials to the residents and family members.2. Resident #1 was admitted to the residence on 5/28/21 with diagnosis including frequent falls and cervical spine fracture.A progress note, dated 4/3/23, read in part that Resident #1 sustained a fall because she was not using her walker.A progress note, dated 4/4/23, read in part that the resident was sitting on the floor' a family member who was with her reported that the resident' s foot got caught under the leg of the chair when she stood up, which caused her to fall.A progress note, dated 5/11/23, read in part that the resident reported she sustained a fall on 5/10/23 but did not report it to the staff at the time.3. Former Resident #5 was admitted to the residence on 9/24/22 with diagnoses including Alzheimer' s Disease. A progress note, dated 9/26/22, read in part that Former Resident #5 fell next to the door of her room.A progress note, dated 9/28/23, read in part that the resident fell in the dining room by pushing he.. Based on record review and interview, the residence failed to update the comprehensive assessment for each resident whenever the resident' s condition changed from baseline status, affecting one sample resident (#4) and one former resident (#5).Findings include:1. Residence PolicyThe residence' s assessment policy, dated 8/20/22, read in part: The residence updated the assessment whenever there was a change in baseline status.2. Resident #4 was admitted to the residence on 1/20/23 with diagnoses including dementia and urinary incontinence.An assessment, dated 3/16/23, read in part that Resident #4 had occasional bladder incontinence, and she required physical assistance with toileting.A progress note, dated 3/23/23, read in part that staff observed the resident on the floor and emergency responders transported her to the emergency department (ED).A hospital discharge plan of care, dated 3/25/23, read that the resident had been diagnosed with a urinary tract infection (UTI).A written practitioner' s order, dated 5/3/23, read in part that Resident #4 was diagnosed with a UTI.A progress note, dated 5/3/23, read in part that the residence received a written practitioner' s order for an antibiotic to treat the resident' s acute UTI.The assessment was not updated when Resident #4 experienced changes in her baseline status after her return to the residence from the ED ..