LIBERTY HEIGHTS ASSISTED LIVING

A relicensure survey and complaint revisit was completed on 5/21/25 for all previous deficiencies cited on 1/8/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation, Chapter VII, was implemented on 3/17/25.

Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy, affecting 42 current residents. This deficiency was cited previously during a survey and complaint investigation concluded on 1/8/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: On 5/21/25 at 7:30 a.m., the residence's involuntary discharge grievance policy was requested; however, the policy provided did not contain all of the required elements. On 5/21/25 at 1:15 p.m., the health and wellness director (HWD) stated she was aware of the current regulation, as the residence had been previously cited with the citation; however, she was unaware the residence's policy had not been updated. The HWD stated the corporate office, which was located in another state, created all of the policies and procedures. Additionally, she stated she did not believe the corporate office understood what the required elements were when they had updated the policy; therfore, that was why it had not been fixed.

A relicensure survey with complaint #CO36153 was completed on 1/8/25. Deficiencies were cited.

Based on record review and interview, the residence failed to provide, upon request, residence documents and other records requested by the department, affecting 42 current residents. Findings include:1. Record Review Resident records were requested as follows:On 1/7/25 at approximately 7:50 a.m., the residence staff and resident roster were requested. The complete resident roster was provided at 12:22 p.m. On 1/7/25, at 8:38 a.m., the following was requested:Access to the residence's electronic health recordResidence policies (including the involuntary discharge grievance policy)Infection control certificate and treatment planEmergency preparation documentationLists of residents who had fallen and were hospitalized Documented grievancesActivities scheduleDocumentation of fire drillsDocumentation of communications with the department's epidemiology teamDocumentation of medication auditsInvestigations of abuseWritten practitioner orders for medications for sample residents. On 1/7/25 at approximately 3:27 p.m., the residence still had not provided their emergency preparation documentation, involuntary discharge grievance policy, infection control certification, grievances, investigations of abuse, lists of resident falls and hospitalizations, medication audits, and signed practitioner orders for sample residents. On 1/8/25 at approximately 3:00 p.m., over one full day after the initial request, all requested items were provided. 2. Interviews On 1/8/25 at 8:17 a.m., the administrator affirmed that the original electronic access the residence provided did not include access to all required documents in the resident records, and the electronic database team (EDT) only gave temporary access that expired at 5:00 pm on 1/7/25, which caused a delay in providing records as requested. On 1/8/25 at approximately 2:40 p.m., the administrator acknowledged the residence's failure to provide records as requested.

Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy, affecting 42 current residents. Findings include:On 1/7/25 the residence involuntary discharge policy was requested at 8:47 a.m. and was provided at 12:47 p.m. The policy did not include all required elements. On 1/8/25 at 3:00 p.m., the administrator was not aware of the current requirement and acknowledged the residence had not updated their involuntary discharge grievance policy to reflect the most recent regulation changes.

Based on observation, record review, and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe 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 42 current residents. Findings include:1. Residence PolicyThe residence's resident agreement dated 2/9/16, read in part: "Services that are included in the monthly service fee is building and apartment maintenance."2. ObservationOn 1/7/25 at approximately 9:45 a.m., the secured environment ' s carpet was frayed in four locations revealing a gap in the carpet, posing a safety hazard. 3. Record ReviewAn electronic message, dated 9/30/24, that listed multiple carpet stains and frayed carpet that posed safety concerns. 4. InterviewsOn 1/7/25 at approximately 10:00 a.m., the memory care director stated that the frayed carpet posed a safety hazard to residents. On 1/7/25 at approximately 10:15 a.m., Staff #2 and #9 stated that the frayed carpet was a safety hazard to the residents. On 1/8/25 at 2:51 p.m., the administrator acknowledged the frayed carpet posed a safety risk to residents, specifically for falling and tripping.

Based on observation, record review, and interview, the residence failed to implement its residence agreement to provide the community with social and recreation activities, and the residence failed to ensure the resident's rights to socialize with other residents and participate in assisted living residence activities in accordance with the care plan affecting all current residents. Specifically, from 12/9 to 12/13/24 (a total of 28 days), the residence failed to provide social or recreational activities that were meaningful to her. Confidential Resident #8 stated that the residence's failure to provide him/her with physical, emotional, and intellectual activities had caused emotional anguish. Findings include:1. Reference and Residence AgreementThe resident agreement, dated 2/9/16, read in part: "The (residence)will provide social and recreation activities, subject to your physical ability to participate ... Services that are included in the monthly service fee is a diverse calendar of social, cultural, recreation and educational programs."2. Record ReviewResident's council minutes, dated 12/13/24, read in part that residents had been negatively affected by the COVID-19 outbreak both physically and emotionally. The residence activity schedule, dated 12/8/24 through 1/6/25 had bold letters at the top page that read: "No Group Activities due to COVID-19 Outbreak Status."An activity schedule, dated 12/8/24, read:8:00 a.m. Joke of the day. 8:30 a.m. Daily chronicle and leisure puzzles delivered with breakfast. 9:00 a.m. [Religious] service on the television in the residents' rooms. 11:00 a.m. [Football] game on the television in the residents' rooms. 2:30 p.m. [Holiday] movie on the television in the residents' rooms. 2:30 p.m. [Football] game on the television in the residents' rooms. 5:00 p.m. [Football] game on the television in the residents' rooms. An activity schedule, dated 12/18/24, read:8:00 a.m. Joke of the day. 9:00 a.m. Daily chronicle and leisure cart. 9:20 a.m. Daily devotional in the residents' rooms. 9:30 a.m. Individual exercise provided with pictures in the residents' rooms. 10:00 a.m. Craft activity in the residents' rooms. 10:15 a.m. Puzzles and art page in the residents' rooms. An activity schedule dated, 12/21/24, read:8:00 a.m. Joke of the day. 9:00 a.m. Daily chronicle in the residents' rooms. 10:00 a.m. Snacks and hydration cart in the residents' rooms. 10:15 a.m. Puzzles and art page in the residents' rooms. 11:00 a.m. [Football] game on the television in the residents' rooms. 2:30 p.m. [Football] game on the television in the residents' rooms. 6:00 p.m. [Holiday] movie in the residents' rooms. On 1/8/25 at approximately 10:00 a.m., the residence electronic information management system revealed the following data:a. Staff #6 visited Resident #5 on 12/18/24 at 10:30 a.m. and discussed family and current events. b. Staff #6 visited Resident #6 was on 12/18 and 12/27/24 at 10:00 a.m. and discussed family and holiday plans. c. An unknown resident's 1:1 data were dated 1/9/25 (a date after the onsite survey: 1/8/25). A care plan for Resident #5 revealed that she did not have a memory deficit and was oriented to person, place, time, and situation. She was able to communicate effectively and make her needs known. Her preferred activities included music, happy hour, walking, gardening, and caring for plants. A care plan for Resident #6 revealed that she required assistance with activities. A care plan for Confidential Resident #8 revealed that s/he preferred group activities and did not have a history of depression or mood disorders. 3. Observation On 1/7/25, a January 2025 activity calendar was posted in a hallway. 4. InterviewsOn 1/7/25 at approximately 12:45 p.m., the administrator affirmed that the COVID-19 outbreak had negatively impacted the residents. She stated that she followed the residence's infection control and mitigation policy and the guidance from the department for the COVID-19 outbreak. The administrator affirmedthat the residence did not host group activities and that the residence was "not business as usual." On 1/8/25 at 9:45 a.m. Staff #6 acknowledged that the January 2025 activity calendar was posted at the beginning of the month despite the residence not following it due to the COVID-19 outbreak. She indicated revisions were made to the January 2025 activity schedule, but they were not posted due to the outbreak. On 1/8/25 at 11:00 a.m., the administrator acknowledged that the residence did not follow the posted January 2025 activity calendar due to the outbreak. During the onsite survey on 1/7/25, Resident #5 stated that the residence provided no group activities during the COVID-19 outbreak from 12/8/24 to 1/6/25. 1/8/25 at approximately 10:00 a.m., Resident #5 stated that the staff did not assist with the exercises listed in the activity schedule. On 1/7/25, Resident #6 reported that the residence had not provided group activities or social distancing activities from 12/8/24 through 1/6/25. She added that the first group activity was during the onsite survey on 1/7/25. Resident #6 expressed that the group exercise benefited her mental and physical health. Confidential Resident #8 shared that due to isolation and the absence of social activities and exercises s/he was unable to sleep at night, was "going crazy," and was depressed. On 1/8/25 at approximately 9:45 a.m., Staff #6 acknowledged that the residence activities listed below were television programs, did not include group activities, and did not include preferred activities for Residents #5, #6, and #8. Staff #6 stated that staff distributed daily activity packets (which consisted of coloring pages and daily chronicles) when they delivered breakfast to the residents. Activities on Sunday 12/8/24 were television programs from 9:00 a.m. to 5:00 p.m. Activities on Wednesday 12/18/24 were 55 minutes of television programs. Activities on Wednesday 12/21/24 were television programs from 11:00 a.m. to 6:00 p.m. On 1/8/25 at approximately 2:45 p.m., the administrator affirmed that she needed to provide meaningful group activities to the residents, especially those who expressed they were "going crazy" and were "depressed."During the onsite survey on 1/7/25, Resident #5 reported that the activity packet did not interest her. During the onsite survey on 1/7/25, Resident #6 stated that she did not utilize the leisure cart. During the onsite survey on 1/7/25, Confidential Resident #8 stated that the residence had not provided a leisure cart in two weeks. On 1/8/25 at approximately 9:45 a.m., Staff #6 acknowledged that the residence restarted the social distancing group activities during the onsite survey on 1/7/24; however, the administrator stopped allowing them to take place on 1/8/25. On 1/8/25 at approximately 11:00 a.m., the administrator affirmed that she again cancelled group activities because the residence was in outbreak status until 1/11/25.

Based on observation, interview, and record review, the residence failed to comply with the authorized practitioner's orders associated with medication administration, affecting two of five current residents (#1,#2) and one former resident (#7). Findings include:1. Resident #2 was admitted to the residence on 9/2/21 with diagnoses including pain in the left shoulder and somnolence (excessive sleepiness or drowsiness). a. TramadolAn external service provider's evaluation, dated 12/30/24, revealed Resident #2 was seen due to a complaint of pain in the left shoulder in October 2024. A written practitioner's order, dated 1/1/25, directed the residence to administer tramadol 25 mg tablets four times daily. However, the November 2024 medication administration record (MAR) revealed that the residence failed to administer tramadol because it was not available from 11/10/24 to 11/13/24. b. EscitalopramA written practitioner's order, dated 1/1/25, directed the residence to administer an escitalopram 5 mg tablet daily at 6:00 p.m. However, the December 2024 MAR revealed that the residence failed to administer the on 12/6/24 because it was not in stock. 2. On 1/8/25 at 2:58 p.m., the administrator stated she expected staff to ensure medications were available and administered as ordered. 3. Additionally, evidence obtained during the on-site visit revealed that the residence failed to comply with authorized practitioner's orders for Residents #1 and #7.

A revisit survey was completed on 10/18/23 for all previous deficiencies cited on 2/16/22. No deficiencies 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