ASSURED SENIOR LIVING 27

A revisit survey was completed on 2/14/24 for all previous deficiencies cited on 11/15/23. 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 revisit survey was completed on 2/14/24 for all previous deficiencies cited on 11/15/23. The facility is in compliance with all deficiencies that were cited.

A relicensure survey was completed on 11/15/23. A deficiency was cited. A change of ownership occurred on 8/3/23.

Based on observation, record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting three of five sample residents for whom medication administration was observed (#1, #4, #5). Findings include:1. Referencesa. According to the Centers for Disease Control and Prevention, "Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surfaces to people when you touch your eyes, nose, and mouth with unwashed hands, prepare or eat food and drinks with unwashed hands, touch surfaces or objects that have germs on them, or blow your nose, cough, or sneeze into hands and then touch other people's hands or common objects." Centers for Disease Control and Prevention (1/8/21), retrieved from: https://www.cdc.gov/handwashing/when-how-handwashing.htmlb. According to the Centers for Disease Control and Prevention, "Change gloves and perform hand hygiene during patient care, if: gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient." Centers for Disease Control and Prevention (1/8/21), retrieved from: https://www.cdc.gov/handhygiene/providers/index.html 2. ObservationsOn 11/15/23 from 8:02 a.m. to 8:09 a.m., Staff #1 removed plastic gloves after preparing breakfast and did not perform any hand hygiene before he prepared medications for Resident #5. Staff #1 touched the computer mouse and his nose, glasses and garbage can lid with his right hand. Staff #1 picked up the ice cream spoon and placed the ice cream in the plastic cup for Resident #5, then stirred the medication with a plastic spoon. Staff #1 took the mixed medication and administered the medication to Resident #5. The plastic spoon was then rinsed with water and placed on the counter. On 11/15/23 at 8:15 a.m., Staff #1 prepared medications for Resident #4 by crushing the medication and mixing them with ice cream. Staff #1 touched Resident #4's water cup, his nose, glasses and the ice cream spoon. No hand washing or disinfecting was observed. Staff #1 used the same plastic spoon to mix and administer Resident #4's medications. On 11/15/23 at 8:25 a.m., Staff #1 touched his nose and did not perform any hand hygiene. Staff #1 placed his glasses on his face and prepared medication for Resident #1. Staff #1 opened the medication bottles with his bare hands, mixed and crushed the medications, opened a medication capsule and emptied the contents into the medication cup. Staff #1 took the ice cream spoon and placed ice cream in the medication cup with crushed medications then returned the spoon to the ice cream jug. Staff #1 used the same plastic spoon to mix and administer Residents #4 and #5's medications. Staff #1 touched Resident #1's water cup and straw with bare hands and administered her medications. No hand hygiene was observed after he administered medications to Resident #1 and then after, he assisted Resident #1 to eat. 3. InterviewsOn 11/15/23 at 8:40 a.m., Staff #1 said he should have washed hands with soap and water before, after and during medication administration. He added he should have used a new plastic spoon between Resident #1, #4 and #5. On 11/15/23 at approximately 12:00 p.m., the administrator said she expected QMAPs to perform hand hygiene after every three residents.

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 7.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. 17.10 An assisted living residence may provide therapeutic diets when the following conditions are met:(A) The diet is prescribed by the resident's practitioner, and(B) The assisted living residence has trained staff to prepare the food in accordance with the diet and ensure it is being served to the appropriate resident. 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 2.2.9.6 Each licensee shall submit to the Department a letter of intent of any change in the information required by Part 2.3.3 of this Chapter from what was contained in the last submitted license application.(A) Changes to the operation of the facility or agency shall not be implemented without prior approval from the Department. A licensee shall, at least thirty (30) calendar days in advance, submit a letter of intent to the Department regarding any of the following proposed changes.(1) Increase in licensed capacity.(a) If a licensee requests an increase in capacity that is approved by the Department, an amended license shall be issued upon payment of the appropriate fee.(b) The Department has the discretion to deny a requested increase in capacity if it determines that the increase poses a potential risk to the health, safety, or welfare of the licensee's clients based upon the licensee's compliance history, or because the licensee is unable to meet the required health and environmental criteria for the increased capacity.

A recertification survey was completed on 11/15/23. A deficiency was cited.

Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting three of five sample participants (residents) for whom medication administration was observed (#1, #4, #5). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.28, requires the assisted living residence to ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. a. According to the Centers for Disease Control and Prevention, "Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surfaces to people when you touch your eyes, nose, and mouth with unwashed hands, prepare or eat food and drinks with unwashed hands, touch surfaces or objects that have germs on them, or blow your nose, cough, or sneeze into hands and then touch other people's hands or common objects." Centers for Disease Control and Prevention (1/8/21), retrieved from: https://www.cdc.gov/handwashing/when-how-handwashing.htmlb. According to the Centers for Disease Control and Prevention, "Change gloves and perform hand hygiene during patient care, if: gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient." Centers for Disease Control and Prevention (1/8/21), retrieved from: https://www.cdc.gov/handhygiene/providers/index.html c. ObservationsOn 11/15/23 from 8:02 a.m. to 8:09 a.m., Staff #1 removed plastic gloves after preparing breakfast and did not perform any hand hygiene before he prepared medications for Resident #5. Staff #1 touched the computer mouse and his nose, glasses and garbage can lid with his right hand. Staff #1 picked up the ice cream spoon and placed the ice cream in the plastic cup for Resident #5, then stirred the medication with a plastic spoon. Staff #1 took the mixed medication and administered the medication to Resident #5. The plastic spoon was then rinsed with water and placed on the counter. On 11/15/23 at 8:15 a.m., Staff #1 prepared medications for Resident #4 by crushing the medication and mixing them with ice cream. Staff #1 touched Resident #4's water cup, his nose, glasses and the ice cream spoon. No hand washing or disinfecting was observed. Staff #1 used the same plastic spoon to mix and administer Resident #4's medications. On 11/15/23 at 8:25 a.m., Staff #1 touched his nose and did not perform any hand hygiene. Staff #1 placed his glasses on his face and prepared medication for Resident #1. Staff #1 opened the medication bottles with his bare hands, mixed and crushed the medications, opened a medication capsule and emptied the contents into the medication cup. Staff #1 took the ice cream spoon and placed ice cream in the medication cup with crushed medications then returned the spoon to the ice cream jug. Staff #1 used the same plastic spoon to mix and administer Residents #4 and #5's medications. Staff #1 touched Resident #1's water cup and straw with bare hands and administered her medications. No hand hygiene was observed after he administered medications to Resident #1 and then after, he assisted Resident #1 to eat.d. InterviewsOn 11/15/23 at 8:40 a.m., Staff #1 said he should have washed hands with soap and water before, after and during medication administration. He added he should have used a new plastic spoon between Resident #1, #4 and #5. On 11/15/23 at approximately 12:00 p.m., the administrator said she expected QMAPs to perform hand hygiene after every three residents.