Lighthouse Assisted Living Inc-Emporia House

A recertification survey was completed on 1/14/26. Deficiencies were cited. Based on observation and interview, the facility (residence) failed to ensure the right of privacy, including the right to be free of alerts on entrances/exits, affecting eight current members (residents).Findings include:During the environmental tour on 1/14/26, the door to the front entrance on the main level of the residence had a code that sounded an alarm when the code was not used to open the door. On 1/14/26, at approximately 9:34 a.m., Staff #1 stated the front door of the residence had a code used to enter and exit the door to ensure resident safety. Staff #1 went on to state if the code was not used prior to opening the front door, an alarm would sound that would alert staff members of residents entering or exiting.On 1/14/26, at approximately 3:30 p.m., the administrator acknowledged not entering a code on the front door of the residence would trigger an alarm that would sound when residents entered or exited without a code so that residence staff were alerted. The administrator stated she was unaware the.. Based on observation, record review, and interview, the facility (residence) failed to protect the right to privacy and dignity of members (residents) by failing to provide a key to the residence and bedrooms, affecting eight current residents. Findings include:The residence' s undated resident rights policy, read that residents shall be observed the right to privacy.On 1/14/26, an environmental tour of the residence revealed two residents asleep in a shared bedroom with the door accessing the bedroom ajar. Another resident was observed walking toward the hallway the shared bedroom was located in. On 1/14/26, at approximately 3:20 p.m., the administrator stated no current residents obtained a key to their bedrooms or to the residence at the time of admission or since admission. The administrator went on to state current residents were given a choice at the time of admission whether to receive keys to the residence and bedrooms, but she was not aware that a key should be provided to residents and left at their di.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at CCR 2505-10 8.7000. 8.7506.F.5.a. Environmental Standards-Home-like quality and feel for Members at all times, and provides Members with unrestricted access to the Alternative Care Facility.

A relicensure survey was completed on 1/14/26. A deficiency was cited. Based on record review and interview the residence failed to appoint an administrator that completed 40 hours of administrator training, affecting eight current residents. Findings include:1. Record ReviewOn 1/14/2026 at approximately 8:00 a.m, the 40-hour administrator training certificate was requested. The residence provided a 40-hour training certificate appointed to the operations manager (OM), but not the listed administrator of the residence. 2. InterviewOn 1/14/26 at approximately 3:34 p.m., the administrator stated she received administrator training and education with her master' s degree in nursing, and believed this education would fulfill the 40-hour administrator training requirements. The administrator went on to state that although she is listed as the administrator of the residence, the OM completed the 40-hour administrator training in lieu of her, and was unaware she was also required to complete the training. The administrator acknowledged that failure to provide the 40-hour administrator training certificate for the appointed administrator of the residence was not in compliance with Chapter VII, 6.5. 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 regulations found at 6 CCR 1011-1, Chapter VII.11.5 The assisted living residence shall review its resident agreements annually and update or amend them as necessary. Amendments to the resident agreement shall also be signed and dated by both parties.

A revisit survey was completed on 4/16/24 for all previous deficiencies cited on 3/10/23. The facility is in compliance with all deficiencies that 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

A relicensure survey was completed on 3/10/23. Deficiencies were cited. Based on observation and interview, the residence failed to mark opened or prepared food that was not used within 24 hours with a "use by" or "discard by" date seven calendar days following opening or preparation, affecting eight current residents.Findings include:On 3/9/23 at approximately 9:00 a.m. and 2:45 p.m., the refrigerator contained items that were opened or prepared without a use by or discard date, as follows:A Ziploc bag of pastaA plastic container of spaghetti sauceTwo packages of sausage pattiesA Ziploc bag of asparagusA plastic container filled with carrots and celeryTwo opened containers of loaded baked potato soupA plastic container filled with an unknown liquidAn opened container of tomato basil soupOn 3/9/23 at approximately 2:00 p.m., the director of operations stated she expected .. Based on observation, interview and record review, the residence failed to ensure food safety training was provided by recognized food safety experts or agencies to staff who served and prepared food, and that evidence of such training was maintained on site, affecting eight current residents.Findings include:1. Observation On 3/9/23 between approximately 7:30 a.m. and 3:00 p.m., Staff #1 prepared and served meals to residents.2. Record ReviewReview of Staff #1' s personnel file, provided by the director of operations (DOO) revealed no record of any training provided by a recognized food safety expert or agency.3. InterviewsOn 3/9/23 at approximately 12:00 p.m., the DOO stated the hire date for Staff #1 was 5/11/21. She added that Staff #1 prepared and served food to residents when she worked.On 3.. Based on record review and interview, the residence failed to ensure the house rules listed all possible actions that might be taken by the residence if any rule was knowingly violated by a resident and failed to address alcohol and marijuana, affecting eight current residents.Findings include:Review of the residence' s undated posted house rules revealed there was no information about the actions that might be taken by the residence if any rule was knowingly violated by a resident. Additionally, the house rules did not address alcohol and marijuana.On 3/9/23 at approximately 2:00 p.m., the director of operations (DOO) stated she was not aware the house rules were required to include possible actions for infractions. On 3/10/23 at approximately 9:15 a.m., the DOO said she was not aware the .. 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 regulations found at 6 CCR 1011-1, Chapter 7.9.1 The assisted living residence shall develop and at least annually review, all policies and procedures. At a minimum, the assisted living residence shall have policies and procedures that address the following items:(D) Investigation of abuse, neglect, and exploitation allegations;(E) Investigation of injuries of known or unknown source/origin;(H) Fall management;(I) Provision of lift assistance, first aid, obstructed airway technique, and cardiopulmonary resuscitation;(J) Unanticipated illness, injury, significant change of status from baseline, or death o..

A recertification survey was completed on 3/10/23. No deficiencies were cited. 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 regulations found at 10 CCR 2505-10, 8.495 Alternative Care Facilities.8.495.4 PARTICIPANT RIGHTSA. An ACF must be integrated in the community and foster the independence of the participant while promoting each participant' s individuality, choice of care, and lifestyle. C. Participants shall be informed of their rights, according to 6 CCR 1011-1, Chapter VII, Section 13. Pursuant to 6 CCR 1011-1, Chapter VII, Section 13.1, the policy on resident rights shall be in a visible location so that they are always available to participants and visitors.2. The following rights may be modified when supported by a specific and assessed need, as determined by the provider, participant, and case manager:f. The right to have visitors at any time;g. The right to control his/her personal resources;h. The right to have access to the entire facility; andi. The right to receive unopened mail.