Woodlake Legacy Senior Living

A revisit survey was completed on 3/13/26 for previous deficiencies cited on 10/15/25. The agency is in compliance with all regulations surveyed. 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 and complaint revist was completed on 10/15/25 for the previous deficiencies cited on 4/9/25. Deficiencies were cited. Tag 0664 was not cited in the previous event; however, the deficiency was included in the previous event' s informational 999 tag. Based on observations, interviews and record review, the residence failed to ensure the residents received the maximum degree of benefit of services, affecting one of eight sample residents (#13).This deficiency was cited previously during a state licensure survey 4/9/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:Resident #15 wa.. Based on record review and interview the residence failed to ensure each staff member, including contracted staff, received training of their specific duties and responsibilities prior to working independently for one of three (Staff #14) staff members. This deficiency was cited previously during a state licensure survey 4/9/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulator.. Based on record review and interview, the residence failed to ensure each staff, including contracted staff, had completed an initial orientation prior to providing resident care for one (Staff #14) of three sampled staff members. This deficiency was cited previously during a state licensure survey 4/9/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.. Based on record review and interview, the residence failed to ensure that each staff member, including contracted staff, met the dementia training requirements for one of three (Staff #14) staff members. This deficiency was cited previously during a state licensure survey 4/9/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:Record reviewP.. Based on record review and interviews the residence failed to identify the highest potential risk, hold, and document routine drills to facilitate staff and resident response to that risk, affecting 97 residents.This deficiency was cited previously during a state licensure survey 4/9/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Record revie.. Based on the interview and record review, the residence failed to ensure personnel files included written documentation of results of background check, and hire dates for two of three staff members(#15 and #16). This deficiency was cited previously during a state licensure survey 4/9/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.. 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 the appropriateness and need for secure environment that included an evaluation by a licensed practitioner that described the resident' s cognitive deficits that contributed to wandering, compromised safety awareness and detailed information from the resident' s family that revealed a history and pattern of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, affecting one of two (#16) resident..

A relicensure survey and change of ownership, with complaints #CO39436 and #CO39780, was completed on 4/9/25. Deficiencies were cited. A change of ownership occurred on 9/30/24. Based on interview and record review, the residence failed to investigate allegations of abuse of residents in accordance with its written policy to include the process for investigating such allegations, how the residence will do.. Based on observation and interview, the residence failed to offer drinks, including water, to residents with every meal, affecting 23 residents in the secure environment.Findings include:On 4/8/25 at approximately 8:00 a.m., 12:3.. Based on observation and interview, the residence failed to store resident medications in a refrigerator that does not contain food, affecting 23 current residents in the secure environment.Findings include:On 4/8/25 at 7:42 a.m., the .. Based on observation, interview and record review, the residence failed to ensure foods were nutritionally balanced, affecting 23 current residents in the secure environment. Findings include:1. 4/8/25 Breakfast MealThe breakfast me.. Based on record review and interview the residence failed to ensure each staff member received training of their specific duties and responsibilities prior to working independently, affecting 101 residents. Findings include:Personne.. Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment that included an evaluation by a licensed practitioner that describ.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of 10 sample residents (#1, #5, #8 and #10).Findings include:Resident .. Based on record review and interview, the residence failed to ensure each staff had completed an initial orientation prior to providing resident care, affecting 101 current residents.Findings include:Personnel files for Staff #1 and #2 in.. Based on record review and interview, the residence failed to ensure that each staff member met the dementia training requirements, affecting 101 current residents.Findings include:Personnel files for Staff #1 and Staff #2 revea.. Based on record review and interview, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, affecting one of 11 sample residents (#5).Resident #5 was adm.. Based on record review and interview, the residence failed to identify the highest potential risk and hold routine drills to facilitate staff and resident response to that risk, affecting 101 current residents.Findings include:The residence' s .. 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 a..

A revisit survey was completed on 8/1/24 for all previous deficiencies cited on 5/2/24. 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 licensure complaint, prompted by #CO35804 and #CO35892, was completed on 5/2/2024. Deficiencies were cited. Based on interviews and record review, the residence failed to implement a fall management program that included detailing in the resident' s care plan the individualized approaches necessary to address fall risks, affecting five of six sample residents (#1-#4, #6). (Cross-reference S1068, S1146)Specifically, Resident #1 fell on 2/29/24 and sustained two red marks on her back. However, the residence failed to update the care plan to address the individualized appr.. Based on observation, interview, and record review, the residence failed to make available, either directly or indirectly through a resident agreement, a safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 24 current residents. (Cross-reference S2812, S3060)Findings include:1. Residence AgreementT.. Based on observation, record review, and interview, the residence failed to ensure each qualified medication administration person (QMAP) had completed a competency assessment with direct observation of all medication administration tasks the QMAPs were assigned to perform for eight of eight sample staff (#1, #3-#9) who were QMAPs affecting 24 current residents in the secure environment (SE).Findings include: The residence Medication Services pol.. Based on observation, record review, and interview, the residence failed to ensure resident care plans contained documentation describing the personal grooming and hygiene items that were deemed safe for the resident and the residents ' access to the items, affecting six of six sample residents (#1-#6). (Cross-reference S1110)Findings include: The residence Resident Assessment and Service Plan policy, dated 5/12/23, read in part that a resident care.. Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated whenever the resident' s condition changed from baseline status, affecting one sample resident (#1). (Cross-reference S1180)1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the reside.. Based on record review and interview, the residence failed to evaluate a resident transferred to another healthcare entity prior to readmission, affecting one resident (#1). (Cross-reference Q1146, Q1180) Findings include:The residence Allowable Health Conditions policy, dated 5/12/23, read in part that the residence reassessed a resident transferred to another healthcare entity prior to the resident' s readmission to the residence. Resident #1 was admitt.. Based on record review and interview, the residence failed to provide a pest control contract or have an effective means for pest control using the least toxic and least flammable effective pesticides, affecting 24 current residents who resided in the secure environment (SE). (Cross-reference S1110)Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 23.3, requires screens or other pest control.. 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 7.14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for oradministered to residents.