Assisted Living of Highlands Ranch

An initial mental health transitional living survey was completed on 3/5/24. A deficiency was cited. Based on observation, interview and record review the facility (residence) failed to ensure residents had the right to privacy and a key to their lockable bedroom door, affecting 12 current persons receiving services (residents).Findings include:The Resident Agreement read in part, residents had the right to privacy. Observations revealed all resident bedrooms had a lockable door; however, residents were not provided with a key to the lock. Observations of shared bedrooms revealed there were two rooms where two residents resided together in each room. The rooms did not have a divider or form of privacy in the room. On 3/5/24 at approximately 8:30 a.m. Staff #2 confirmed residents were not provided keys to the locks on their bedroom doors. Staff #2 additionally stated that all of the bedroom locks utilized the same key which staff kept in the medication cart. On 3/5/24 at approximately 9:20 a.m. Resident #3 stated the rooms were not private and she did not like having to change her clothes in front of her roommate. She further stated she had requested, approximately two months prior to the onsite, that a curtain be put up in her bedroom to provide privacy; however, one was not put up. On 3/5/24 at approximately 11:00 a.m. the administrator stated that curtains for the shared rooms were purchased; however, were not yet installed. The administrator additionally stated he knew residents should have keys to their bedrooms and did not know that all of the bedroom locks used the same key.

A change of ownership survey was completed on 3/5/24. Deficiencies were cited. Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy affecting 12 current residents.Findings include:The residence' s discharge policy dated 10/26/22, read in part: "1) A resident shall be discharged only for one or more of the following reasons: a) when the facility cannot, despite reasonable efforts consistent with industry standards, assure that the resident will not harm him or herself or others. b) When the facility is no longer able to meet the resident' s identified needs. c) nonpayment for basic services/non-reimbursement of services not included and medications in accordance with the resident agreement. d) failure of the resident to comply with written policies and rules of the facility, which contains notice that discharge may result from violation of such policy or rule. e) when a resident poses a danger to self or other residents. f) When a resident becomes loud, combative and/or disrupts other residents to the extent that in the facility' s sole discretion, it is reasonable to insist upon discharge. g) Uncontrolled bowel or bladder habits. If the resident is not cognitive enough to know to keep his depends on and in place. Staff will assist with diaper/depends placement and remind resident to use the bathroom every two hours during the day. This includes colostomy bags; resident must maintain colostomy care with minimal assistance. Staff will also assist in colostomy bag replacement. h) Wandering behavior that is not reasonably controlled through occasional redirection by staff and/or other means. 2) The resident or resident' s legal representative shall have thirty (30) days advance written notice of discharge except in cases of medical emergency, or for the physical safety of the resident or others in which case notice will be as soon as reasonably practicable. A copy of the thirty (30) day written notice shall be sent to the state or local ombudsman on the same day that it is provided to the resident. Facility will include the phone number of other assisted living residences including the pho..