Waneka Park Assisted Living

A complaint revisit was completed on 2/17/26 for all previous deficiencies cited on 11/6/25. A deficiency was cited. Based on record review and interview, the residence failed to comply with the authorized practitioner' s orders associated with medication administration, affecting one of three sample residents (#7).This deficiency was cited previously during a complaint survey on 11/6/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #7 was admitted to the residence on 7/2/21 with diagnoses including osteoarthritis, chronic pain and restless leg syndrome.A written practitioner' s order, dated 12/22/25, directed the residence to administer oxycodone 5 mg four times daily. However, the January 2026 medication administration record (MAR) for Resident #7 read the medication was unavailable and not administered on 1/14/26; 4:00 p.m. dose. On 2/17/26 at approximately 3:30 p.m., the health and wellness director acknowledged the oxycodone medication was out of stock and not administered on 1/14/26.On 2/17/26 at approximately 4:30 p.m., the administrator said she expected medications to be administered according to their practitioner' s orders and not run out of stock. The administrator said the reason this deficiency was not corrected was because of ongoing issues with an outside service provider that provided this resident' s medications.

A licensure complaint, prompted by #CO41482, was completed on 2/17/26. Deficiencies were cited. Based on interviews and record review, the residence failed to comply with conditions imposed by the department on the license, affecting 66 current residents.Findings include:The department completed a complaint survey on 7/23/25. The residence failed to ensure residents were treated with dignity and respect and was cited tag T1322 at a C level for harm.The department determined the residence violated statutory and regulatory requirements necessitating that the department impose an intermediate condition on 8/13/25. The residence was required to pay a civil fine of $500 by 9/12/25.The residence did not appeal the intermediate condition.Review of the department database revealed the residence had not yet paid the civil fine as of 2/17/26.A department representative confirmed that the residence had not paid the civil fine as of 2/12/26.On 2/17/26 at 4:20 p.m., the administrator stated she was aware of the fine issued in July 2025 but she was unaware that the residence failed to pay the fine by the due date. Based on interviews and records, the residence failed to investigate, report and document allegations of abuse, affecting two of four sample residents (#15 and #19).Findings include:1. ReferencesChapter 7 regulations governing assisted living residences, section 13.11 (C) (D) (E) (F) (G) reads in part, the assisted living residence shall investigate all allegations of abuse of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: The process for investigating such allegations; How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; A requirement that the resident shall be protected from potential future abuse while the investigation is being conducted; A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. 2. PolicyReview of the residents ' most recent abuse, neglect and exploitation prevention policy, dated 1/26/18, defines abuse as the willful infliction of injury, intimidation or punishment resulting in physical harm or mental anguish. Further the policy defines verbal abu..

A certification complaint, prompted by #CO41483, was completed on 2/17/26. A deficiency was cited. Based on interviews and records, the facility (residence) failed to investigate, report and document allegations of abuse, affecting two of four sample members (residents) (#15 and #19)Findings include:1. ReferencesChapter 7 regulations governing assisted living residences, section 13.11 (C) (D) (E) (F) (G) reads in part, the assisted living residence shall investigate all allegations of abuse of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: The process for investigating such allegations; How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; A requirement that the resident shall be protected from potential future abuse while the investigation is being conducted; A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. 2. PolicyReview of the residents ' most recent abuse, neglect and exploitation prevention policy, dated 1/26/18, defines abuse as the willful infliction of injury, intimidation or punishment resulting in physical harm or mental anguish. Further the policy defines verbal abuse in part as threats of harm and physical abuse includes hitting, slapping, pinching and/or kicking.Further, review of the residents ' abuse, neglect and exploitation prevention policy and procedures read in part, should an incident or suspected incident of resident abuse, mistreatment, neglect or injury be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The facility' s investigation will be documented on the required stated investigation form and the Administrator will provide the facility' s completed documentation, including witness statements and other supporting documents to..

A licensure complaint, prompted by #CO41106, was completed on 11/18/25. Deficiencies were cited. Based on interview and record review, the administrator failed to manage the day to day delivery of services to ensure residents received the care that was described in their resident agreements and resident care plans, in addition to training and completing and maintaining all records required by the Department, affecting 66 current residents. (Cross-reference U647, U1130, U1150, U1194)Findings include:1. Residence PolicyThe residence' s undated Resident Agreement, read, in part, "All personal care services provided by us to you in accordance with your resident care plan are covered by your personal care fee ... Your resident care plan is a written document that includes a descri.. Based on interview and record review, the residence failed to reflect detailed personal service needs and the staff tasks necessary to meet those needs in the care plan affecting one former resident (#18) (Cross reference U1194).Findings include:1. Former Resident #18 was admitted to the residence on 12/6/24 with a diagnosis of parkinsonism, abnormalities of gait and mobility.The care plan for Former Resident #18, dated 10/1/24, read she required two person assistance with transferring.2. InterviewsOn 11/17/25 at 10:44 a.m., Staff #11 stated Former Resident #18 was in the hospital following a fall. Staff #11 said Former Resident #18 was a fall risk and fell often. She.. Based on observation, record review, and interview, the residence failed to ensure that each staff member received training related to fall management and fall prevention for two sample staff (#9, #10) affecting 66 current residents. (Cross-reference U540)Findings include:On 11/17/25, during the on-site visit from approximately 10:00 a.m. to 4:30 p.m., Staff #9 and Staff #10 were observed providing care and services to residents.On 11/17/25, review of personnel files for Staff #9 and Staff #10 revealed hire dates of 8/18/2025 and 9/29/25, respectively. Neither personnel file revealed any training on recognizing fall management and fall prevention training, as required prior to working indep.. Based on record review and interview, the residence failed to contact a resident' s primary practitioner when the resident sustains an injury or accident, affecting two of three sample residents (#7, #16). (Cross-reference U540)Findings include:1. Resident #16 was admitted to the residence on 10/31/25.A late entry progress note, dated 11/8/25, read in part, Resident #16 experienced an unwitnessed fall resulting in a skin tear to the right forearm on 11/6/25. The progress note did not indicate that a practitioner ' s assessment had been completed, nor did it indicate Resident #16 ' s primary practitioner had been notified of the fall and injury. A progress note, dated 11.. Based on record review and interview, the residence failed to document any out of the ordinary event or issue that affected a resident' s physical, behavioral, cognitive and functional condition, along with the action taken by staff to address that residents changing needs, affecting one former resident (#18). (Cross-reference U540, U1130)Findings include:Former Resident #18 was admitted to the residence on 12/6/24 with diagnoses including parkinsonism, abnormalities of gait and mobility and repeated falls.An investigation written by Staff #12, dated 11/10/25 read, in part, "(Former Resident #18) had a fall earlier in the day and a caregiver had helped her up and hurt her hand while ..

A certification complaint, prompted by #CO41105, was completed on 11/18/25. A deficiency was cited. Based on interview and record review, the facility (residence) failed to ensure that each resident care plan reflected the member (resident) goals, choices, preferences, and needs and incorporation of these elements into the supports and services described in the Person-Centered Support Plan, affecting one former resident (#18).Findings include:1. Former Resident #18 was admitted to the residence on 12/6/24 with a diagnosis of parkinsonism, abnormalities of gait and mobility.The care plan for Former Resident #18, dated 10/1/24, read she required two person assistance with transferring.2. InterviewsOn 11/17/25 at 10:44 a.m., Staff #11 stated Former Resident #18 was in the hospital following a fall. Staff #11 said Former Resident #18 was a fall risk and fell often. She added Staff #7 lifted up Former Resident #18 by herself. On 11/17/25 at 1:37 p.m., Staff #6 stated Staff #11 called for help and said Former Resident #18 fell on the floor. Staff #6 said she had not used the sit to stand lift with Former Resident #18' s for transfers. On 11/17/25 at 2:14 p.m., Resident #18 ' s family member said Former Resident #18 did not require two staff members to transfer her, as he was told by the administrator that the residence did not provide two person transfer assistance and that is why he bought the sit to stand mechanical lift so that one staff member could use the lift to transfer Former .. 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 8.7000. 8.7411.A Incident reportingProvider Agencies shall complete the timely reporting, recording, and reviewing of incidents which shall include, but not be limited to: 2. Hospitalization of Member receiving services; 3. Medical emergencies, above and beyond first aid, involving Member receiving services; 5. Injury to Member or illness of Member.