Assisted Living of Lakewood LLC

A re-licensure survey was completed on 7/1/25. Zero deficiencies were cited. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.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 710.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.

An initial licensure survey was completed on 4/4/24. A deficiency was cited. Based on observations and record review, the residence failed to be in compliance with all applicable regulations. This failure created the potential for mismanagement of care and services for the residents who would be served by this residence.Findings include:1. Resident' s rights to privacy- Chapter II section 3.2.4 Facilities and agencies are expected to maintain the facility to the FGI Guidelines under which the Department approved the facility' s or agency' s initial license until such time as a new guideline compliance review occurs as required by this Part 3.- FGI Section 4.1-2.2.2.4(1) Visual privacy shall be provided for each resident in multiple-bed rooms. - FGI Section 4.1-2.2.2.4(2) Design for privacy shall not restrict resident access to the toilet, room entrance, window, or other shared common areas in the resident room.- 6 CCR 1011-1 Chapter 7 section 13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: (A) The right to privacy.a. The southeast and northeast bedrooms on the lower level did not have a form of privacy for one sleeping area. b. The privacy curtains in the shared northeast bedroom upstairs and the shared southwest bedroom downstairs blocked access to the window for one of the residents in the shared room. c. On 4/4/24 at approximately 9:30 a.m. the administrator confirmed the curtains did not provide full privacy for one of the residents in each of the rooms on the lower level and stated they needed to rework how the curtains were set up. 2. Recreational Equipment- Chapter VII section 12.32 Each assisted living residence shall provide sufficient recreational equipment and supplies to meet the needs of the resident engagement program. Special equipment and supplies necessary to accommodate persons with special needs shall be..

An initial certification of the mental health transitional living program was completed on 4/4/24. Deficiencies were cited. Based on observation and interview the setting failed to ensure all bedroom doors were lockable with a lock and key for two individuals who would share a bedroom. Findings include:The shared bedroom on the upper level southeast side of the facility had a sliding pocket door as the entrance door into the room. The pocket door did not have a lock on it. On 4/4/24 at approximately 9:30 a.m. the director of maintenance confirmed there was not a lock on the door and stated a new door would need to be installed because it would not be possible to add a lock to the pocket door. On 4/4/24 at approximately 10:00 a.m. the administrator confirmed the pocket door on the bedroom was not lockable. Based on observation and interview, the setting (residence) failed to ensure the right of privacy to allindividuals (residents) who would be served by this setting.Findings include:a. The southeast and northeast bedrooms on the lower level did not have a form of privacy for one sleeping area. b. The privacy curtains in the shared northeast bedroom upstairs and the shared southwest bedroom downstairs blocked access to the window for one of the residents in the shared room. Additionally, one side of the southeast bedroom upstairs contained the entrance to the bedroom; therefore, the resident who resided on the other side of the room would encroach on the resident' s privacy who resided next to the entrance door. c. On 4/4/24 at approximately 9:30 a.m. the administrator confirmed the curtains did not provide full privacy for one of the residents in each of the rooms on the lower level and stated they needed to rework how the curtains were set up.