Lighthouse Assisted Living INC - Wadsworth

. Based on interviews and records reviews the residence failed to implement a fall management program, which included detailing in each resident ' s care plan the individualized approach necessary to address fall risks, affecting one (#9) of four sample residents.Findings include:1. Residence PolicyThe residence' s undated Fall Management Policy, read in pertinent part, states: "Assess all residents upon admission and after any fall, change in condition, or medication adjustment. Update care plans accordingly. Complete fall incident notes with date/time, circumstances, assessment, actions, notifications, and prevention measures."2. Resident #9 was admitted to the residence on 7/24/25. Progress notes in Resident #9' s record revealed the following:On 8/28/25, Resident #9 fell out of bed with no injury. On 10/1/25, Resident #9 fell on the floor. A skin tear was observed on Resident #9 ' s right arm. A care plan for Resident #9 dated July 2025 did not include any fall interventions.3. InterviewsOn 10/27/25 at approximately 3:00 p.m., Staff #2 was interviewed and did not understand the training on the individualized approach necessary to address Resident #9' s falls.On 10/27/25 at 3:00 p.m., Staff #1 was interviewed and did not understand the training on the individualized approach necessary to address Resident #9' s falls.On 10/27/25 at 1:41 p.m., the administrator said she did not change Resident #9' s plan to add individualized approaches necessary to address fall risks and was not sure what could have been done differently related to individualized approaches because the falls were unobserved and he only fell twice in two months. The administrator said they could do a better job at documenting falls when they occur. A licensure complaint revisit was completed on 10/27/25 for all previous deficiencies cited on 12/9/24. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new regulation 6 CCR 1011-1, Chapter 7 was implemented on 7/1/25.

A licensure complaint, prompted by #CO38365, was completed on 12/9/24. Deficiencies were cited. Based on interview and record review the residence failed to implement a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks, affecting two of two (#5, #6) sample residents who fell. (Cross-reference S0410, S0430 S1410, S1192, S1324 and S2230)Specifically, Former Resident #6 was admitted to the residence because he fell at home and was a fall risk. Former Resident #6 fell on 11.. Based on interview and record review, the residence failed to ensure resident records contained progress notes and documentation of on-going services provided by external service providers (ESPs) including practitioners, affecting one sample resident (#6). (Cross-reference S0410, S0430, S1410, S1180, S1192, and S1324 )Findings include:On 12/5/24 at approximately 9:30 a.m., progress notes for Former Resident #6 for November 2024 were requested regarding a speci.. Based on interview and record review, the residence failed to investigate an allegation of neglect in accordance with its written policy which included reporting an allegation of neglect to the adult protective services (APS) of the appropriate county Department of Social Services, affecting 10 current residents. (Cross-reference S0410, S0430, S1180, S1192, S1324 and S2230)Findings include:1. Record reviewOn 12/5/24 at approximately 2:00 p.m., the admini.. Based on interview and record review, the residence failed to report suspected caretaker neglect to law enforcement within 24 hours of discovery, affecting former resident (#6). (Cross-reference S0430, S1180, S1192, S1324 and S2230)Findings include:1. Residence PolicyThe residence' s undated policy for investigating allegations of abuse or neglect read in part that all staff reported suspected neglect of a resident to the appropriate supervisor, and the ad.. Based on interview, and record review, the residence failed to observe resident rights in the care, treatment, and oversight of residents and their right to be free from neglect, affecting one former sample resident (#6). (Cross-reference S0410, S0430, S1410, S1180, S1192 and S2230)Specifically, Former Resident #6 was admitted to the residence on 10/27/23 with diagnosis including myotonic dystrophy (a genetic disorder that causes progressive muscl.. Based on record review and interview the residence failed to ensure residents needing lift assistance were evaluated properly to determine whether lift assistance was appropriate by staff, affecting one of two sample residents (#5) and a former resident (#6). (Cross reference S0410, S0430, S1180, S1192, S1324 and S2230)Findings include:Former Resident #6 was admitted to the residence on 10/27/23 with diagnoses including myotonic dystrophy (a genetic disor.. Based on record review and interview, the residence failed to comply with occurrence reporting requirements, affecting one sample former resident (#6) who alleged neglect. (Cross-reference S0410, S1410, S1180, S1192, S1324 and S2230)According to the Occurrence Reporting Manual, dated May 2018, the residence must report an occurrence to the Department when: "Any occurrence involving physical ... abuse of a patient or resident, as described in..

A relicensure survey was completed on 10/9/24. Deficiencies were cited. Based on interview and record review, the residence failed to develop and implement an involuntary discharge grievance policy, affecting nine current residents.Findings include:On 9/9/24, the residence' s involuntary discharge policy did not include all of the required elements.On 9/9/24 at approximately 1:30 p.m., the administrator said the residence only had one discharge policy, including involuntary discharge. The administrator said the residence' s current discharge policy was missing the required elements. The administrator said she was not aware of the new requirement. Based on observation, record review 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) so that the information was readily available to staff at all times, affecting nine current residents.Findings include:On 10/9/24 at approximately 7:45 a.m., an environmental tour of the residence revealed there was no list of staff who had current certification in first aid or CPR in a visible location inside the residence. On 10/9/24 at approximately 1:00 p.m., the secondary administrator toured the residence and acknowledged there were no visible lists of staff with CPR and first aid certifications in the residence. She said the residence should have this posted in case of an emergency. The secondary administrator said she had thought they had posted it.