Libby Bortz Assisted Living Center

A relicensure survey with complaint #CO35279 was completed on 9/24/24. Deficiencies were cited. Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy affecting 85 current residents.Findings Include:The residence' s grievance policy, dated 1/8/20, read.. Based on interview and record review the residence failed to ensure the resident roster contained all the required elements affecting 85 current residents.Findings IncludeThe residence' s resident roster, provided by the administrato.. Based on interview, and record review, the residence failed to have at least one staff member onsite who had certification in first aid from a nationally recognized organization, affecting 85 current residents. (Cross-reference 0.. Based on observation and interview the residence failed to place in a visible location a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR), affecting 85 current residents. (Cross-reference 07.. Based on observation, interview and record review the residence failed to comply with authorized practitioner' s orders affecting four of eight sample residents (#1, #2, #5, #9). Findings Include1. Residence Policy titled Medication Admini.. Based on observation, interview, and record review the residence failed to ensure residents had the right to full use of the assisted living residence common areas in compliance affecting 85 current residents. (Cross-reference 1382)Findi.. Based on observations, record review, and interview, the residence failed to ensure that residence house rules did not contradict, discourage, or hinder resident ' s exercise of his or her rights, affecting 85 current residents. (Cross-refer.. Based on record review and interview the residence failed to develop and follow written policies and procedures to ensure the continuation of care to all residents for at least 72 hours immediately following an emergency affecting 8.. Based on record review and interview the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor on a quarterly basis, audited the accuracy and completeness of the medicat.. Based on record review and interview the residence failed to have at least one staff member onsite at all times certified in cardiopulmonary resuscitation (CPR) affecting 85 current residents. (Cross-reference 0732, 0736) .. Based on record review and interview the residence failed to include key components in their policies and procedures regarding the visitation rights of the residents affecting 85 current residents. (Cross-reference 1382)Findings include:.. Based on record review and interview the residence failed to provide each staff with training relevant to their specific duties and responsibilities prior to them working independently, affecting 85 current residents.Findings include:1. Pe.. Based on record review and interview, the residence failed to have personnel files for current and volunteer employees readily available and onsite for department review for for two staff of three staff (#2 and #3) affecting 85.. Based on record review and interview, the residence failed to provide, upon request, residence documents, staff information and access to full resident records affecting nine (#1-#9) current residents and one (#10) former resident.. Based on record review, and interview, the residence failed to update a resident care plan that reflected the most current assessment information, promote resident mobility and safety and detail specific service needs along with th.. 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 regul..