ASSURED SENIOR LIVING 18

A licensure complaint, prompted by #CO42331, was completed on 7/16/26. No deficiencies were cited.

A revisit survey was completed on 2/3/26 for all previous deficiencies cited on 10/13/25. 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 10/13/25. A deficiency was cited.

Based on observation and interview, the residence failed to have a locked cabinet to store medications when unattended by qualified medication administration persons (QMAP) or other licensed staff, affecting six current residents. Findings include:1. ObservationOn 10/13/25 at 8:30 a.m., Staff #1 had unlocked the medication cart located in the residence's kitchen, then walked away from the medication cart to attend to Resident #1 in her bedroom down the hall. Staff #1 failed to lock the medication cart before leaving the cart. At 11:09 a.m., Staff #1 had unlocked the medication cart located in the residence's kitchen, then walked away a second time from the medication cart without locking it. Residents were present and ambulating in the common areas of the residence. 2. InterviewOn 10/13/25 at 11:09 a.m., Staff #1 acknowledged he forgot to lock the medication cart prior to walking away both times. He stated that he was trained to lock the medication cart and that the cart should be locked at all times when unattended. On 10/13/25 at 3:02 p.m., the administrator stated the medication cart should be locked at all times when staff are not in front of it. She stated she was aware it had been unlocked twice today and expected it to remain locked. She stated that staff had been trained on locking the cart when unattended.

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.10.1 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. 10.6 Each assisted living residence's emergency policies shall address, at a minimum, all of the following items: (A) Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations;(B) A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; (C) When to evacuate the premises and the procedure for doing so; (D) A pre-determined means of communicating with residents, families, staff and other providers; (E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; (F) Storage and preservation of medications; (G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; (H) Protection and transfer of health information as needed to meet the care needs of residents; and (I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. 14.39 Controlled substances shall be kept in double lock storage. (A) Two individuals who are either qualified medication administration persons, nurses, or practitioners shall jointly count all controlled substances at the end of each shift and sign documentation regarding the results of the count at the time it occurs. Any discrepancy in the controlled substance count shall be immediately reported to the administrator.

A recertification survey was completed on 10/13/25. No deficiencies were cited.

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 10 CCR 2505-10 8.7000.8.7408 Policies and Procedures (A) Provider Agencies shall establish and maintain policies and procedures for each of the items below. 12. Written Plans to Address Emergenciesa. An emergency can be defined as an unforeseen situation that may endanger the lives of Members and/or staff, as well as disrupt for a short time the normal operations within a setting or Agency. b. Emergencies can include, but are not limited to: i. Medical Emergencies ii. Public Health Emergencies iii. Fireiv. Natural Disasters c. Each HCBS Provider Agency shall have written policies and procedures to address emergencies, unless otherwise specified within service regulations. i. Plans should include how the agency prepares for loss of staff, various emergencies, back up plans, protocols, etc. should any staff be affected. ii. Day Habilitation services shall have written plans to address emergencies regardless of service location or type of program.

A certification complaint, prompted by #CO33650, was completed on 3/12/24. No deficiencies were cited.

A licensure complaint prompted by #CO33649 was completed on 3/12/24. No deficiencies were cited. A change of ownership occurred on 8/3/23.

A revisit survey was completed on 8/2/23 for all previous deficiencies cited on 10/27/22. No deficiencies were cited.

A revisit survey was completed on 8/2/23 for all previous deficiencies cited on 10/27/22. 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