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 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 .. 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. Findin.. 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.. 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 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 reside..

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