EXTENDED FAMILY ASSISTED LIVING INC

An administrative relicensure survey was completed on 4/20/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40583, was completed on 3/23/26. A deficiency was cited.

Based on observations, interviews, and record review, the residence failed to ensure that additions, renovations, or construction complied with applicable Facility Guidelines Institute (FGI), affecting 8 current residents. Findings include: 1. ObservationsAn environmental tour of the residence on 3/19/2026 at 7:40 a.m through 3:20 p.m. revealed two additional resident sleeping rooms had been constructed. These rooms were reflected on the residence ' s approved by the city per contractor request floor plans and appeared to be newly added to the home, however the Life Safety Code department was not notified of the construction and has not conducted their survey to ensure all guidelines were followed as required. Resident #5 resided in the newly constructed double occupancy room. Observations were conducted on 3/19/26 at 9:25 a.m of an area that was new construction. The area walls were extended in order to provide a dining area and also more walking egress for the residents as it aligned with a hallway. This new construction had required multiple new outlets and electrical work to be completed. The city's permit for construction revealed the residence began construction on 6/3/25 and ended 11/30/25. However, the residence was unable to provide documentation of FGI guideline compliance as required on 3/19/26 at 9:35 a.m. 2. Record review On 3/19/26 documentation of approved construction plans permits or plan review in accordance with FGI was requested and not provided 3. InterviewAn interview with the administrator on 3/19/26 revealed that the residence could not provide documentation of approved construction plans, permits, or evidence of plan review in accordance with FGI.On 3/19/26 at 7:37 a.m the life safety inspector stated that the residence did not contact or reach out to them about planned or completed construction. However the Life Safety Code department was not notified of the construction and has not conducted their survey to ensure all guidelines were followed as required. Resident #5 resided in the newly constructed double occupancy room. On at 3/19/26 at 9:23 a.m the administrator stated she initiated construction because Resident #5's previous room was small and she wanted to build bigger bedrooms. The administrator stated some of the rooms were too small for residents to ambulate comfortably, so she made an addition and added a dining room and one double occupancy bedroom. However, she stated she left all planning and approvals to the contractor to sort out so she was not aware of the requirement that all renovation and construction had to follow FGI guidelines.

An LSC complaint survey, prompted by #CO41881, was completed on 3/19/2026. No deficiencies were cited.

A revisit survey was completed on 4/23/24 for all previous deficiencies cited on 10/17/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 4/23/24 for all previous deficiencies cited on 10/17/23. The facility is in compliance with all deficiencies that were cited.

A relicensure survey was completed on 10/17/23. Deficiencies were cited.

Based on observation, record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for two sample staff (#1, #2), affecting six current residents. (Cross-reference Q0664)Findings include:1. ReferencesChapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following items:(E) Results of background checks and follow up, as applicable. 2. ObservationsOn 10/17/23 from 7:30 a.m. to 3:00 p.m., Staff #1 worked in the residence. 3. Record Review Review of personnel files for Staff #1 and #2 revealed the were hired September 2021 and 8/17/21, respectively. Review of the personnel files for Staff #1 and #2 revealed the following: Staff #1's record did not contain evidence of CBI results or hire date. Staff #2's record did not contain evidence of CBI results. Review of the staff list revealed Staff #1 and #2 worked at the residence as follows:Staff #1 worked at the residence Friday-Sunday. Staff #2 worked at the residence Monday-Thursday. 4. Interview On 10/17/23 at 2:04 p.m., the administrator stated she was unaware the personnel files for Staff #1 and #2 did not contain their CBI results. She stated the CBI background checks for Staff #1 and #2 had been completed prior to their hire date. The administrator stated in 2022, a heat treatment had been conducted at the residence and they had to remove all of the files from the premises. She stated it was possible the CBI background checks for Staff #1 and #2 had somehow been misplaced.

Based on record review and interview, the residence failed to ensure each personnel file included the required information, affecting two of two sample staff for whom there was a personnel file (#1, #2). (Cross-reference Q0610)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 7.8 (A), requires the assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics:(1) The care and services provided by the assisted living residence;(2) Assignment of duties and responsibilities, specific to the staff member or volunteer;(3) Hand Hygiene and infection control;(4) Emergency response policies and procedures, including:(a) Recognizing emergencies,(b) Relevant emergency contact numbers,(c) Fire response, including facility evacuation procedures(d) Basic first aid,(e) Automated external defibrillator (AED) use, if applicable,(f) Practitioner assessment, and(g) Serious illness injury, and/or death of a resident.(5) Reporting requirements, including occurrence reporting procedures within the facility;(6) Resident rights;(7) House rules;(8) Where to immediately locate a resident's advance directive; and(9) An overview of the assisted living residence's policies and procedures and how to access them for reference.b. Chapter VII regulations governing assisted living residences, part 7.8 (B), requires the assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, selfstudy courses, or on-the-job training, and shall include, but is not limited to, the following topics:(1) Overview of state regulatory oversight applicable to the assisted living residence;(2) Person-centered care;(3) The role of and communication with external service providers;(4) Recognizing behavioral expression and management techniques, as appropriate for the population being served;(5) How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served;(6) Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility;(7) How to safely provide lift assistance, accompaniment, and transport of residents;(8) Maintenance of a clean, safe and healthy environment including appropriate cleaning techniques;(9) Food safety; and(10) Understanding the staff or volunteer's role in end of life care including hospice and palliative care. 2. Record Review Review of the personnel files for Staff #1 and #2 were hired September 2021 and 8/17/21, respectively. The files revealed the following was not included in their files:Staff #1: Date of hire and date duties commenced, orientation and training, evidence of CBI results, nor the results of CAPS background checks. Staff#2: Evidence of CBI results or the results of CAPS background checks. 3. Interview On 10/17/23 at 2:04 p.m., the administrator stated she could not recall the exact date Staff #1 was hired; however, it was sometime in September 2021. She stated she was aware the hire date should have been included in Staff #1's file. The administrator stated Staff #1 had completed orientation and training prior to providing resident care; however, she did not know what happened to the documentation. Additionally, the administrator stated she was unaware the personnel files for Staff #1 and #2 did not contain their CBI results. She stated the CBI background checks for Staff #1 and #2 had been completed prior to their hire date. The administrator statedin 2022, a heat treatment had been conducted at the residence and they had to remove all of the files from the premises. She stated it was possible the CBI background checks for Staff #1 and #2 had somehow been misplaced.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 27 current residents. (Cross-reference Q0734)Findings include: 1. Referencea. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training" Brouhard, R., EMT (11/30/21) First Aid, 10 Basic First Aid Procedures, retrieved from: https://www.verywellhealth.com/basic-first-aid-procedures-12985782. Observation On 10/17/23 from 7:30 to 3:00 p.m., Staff #1 was the only care staff onsite. Staff #1 was observed administering medications and providing personal care needs to residents. 3. Record Review On 10/17/23 at 1:30 p.m., the first aid certification was provided for Staff #1; however, his certification expired on 9/25/23. 4. InterviewsOn 10/17/23 at 2:02 p.m., Staff #1 stated he had been certified in first aid; however, he was unaware his certification had expired on 9/25/23. He stated Staff #2 worked at the residence Monday-Thursday and he worked Friday-Sunday. Staff #1 stated both he and Staff #2 lived at the residence so there was always a certified staff onsite at all times; however, Staff #2 was currently on vacation. Staff #1 stated Staff #2 had left earlier that morning and was not coming back until 10/19/23. On 10/17/23 at 2:04 p.m., the administrator stated she was aware that at least one first aid certified staff should have been onsite at all times. However, she was unaware that Staff #1's first aid certification had expired on 9/25/23. The administrator stated she was responsible for tracking when staff first aid certifications were about to expire; however, she had been so busy recently, it had unfortunately gone unnoticed.

Based on interview and record review, the residence failed to ensure at least one staff member was onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting six current residents. (Cross-reference Q0732)Findings Include:1. Referencesa. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (5/1/21) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600b. According to Mayo Clinic, "Choking happens when an object lodges in the throat or windpipe blocking the flow of air. Choking is life-threatening. It cuts off oxygen to the brain. Give first aid as quickly as possible if you or someone else is choking." Mayo Clinic (10/11/22) Choking: First Aid, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art-200566373. Record Review 2. Record ReviewOn 10/17/23 at 1:30 p.m., the CPR certification was provided for Staff #1; however, his certification had expired on 9/25/23. 4. InterviewsOn 10/17/23 at 2:02 p.m., Staff #1 stated he had been certified in CPR; however, he was unaware his certification had expired on 9/25/23. He stated Staff #2 worked at the residence Monday-Thursday and he worked Friday-Sunday. Staff #1 stated both he and Staff #2 live at the residence so there was always a certified staff onsite at all times; however, Staff #2 was currently on vacation. Staff #1 stated Staff #2 had left earlier that morning and was not coming back until 10/19/23. On 10/17/23 at 2:04 p.m., the administrator stated she was aware that at least one CPR certified staff should have been onsite at all times. However, she was unaware that Staff #1's CPR certification had expired on 9/25/23. The administrator stated she was responsible for tracking when staff CPR certifications were about to expire; however, she had been so busy recently, it had unfortunately gone unnoticed.

Based on record review and interview, the residence failed to ensure medication audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting six current residents. Findings include:On 10/17/23 at 7:45 a.m., Staff #1 was requested to provide the residence's quarterly medication cart audits; however, he was unable to provide the documentation. On 10/17/23 at 2:00 p.m., the administrator stated the pharmacy the residence used conducted the medication cart audits on a monthly basis; however, she had not participated with the audits. She stated she had conducted the audits in the past; however, could not recall exactly when the pharmacy had taken over that duty.

A recertification survey was completed on 10/17/23. 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 medication administration regulations, affecting six current participants (residents). Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.31, requires 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. On 10/17/23 at 7:45 a.m., Staff #1 was requested to provide the residence's quarterly medication cart audits; however, he was unable to provide the documentation. On 10/17/23 at 2:00 p.m., the administrator stated the pharmacy the residence used conducted the medication cart audits on a monthly basis; however, she had not participated with the audits. She stated she had conducted the audits in the past; however, could not recall exactly when the pharmacy had taken over that duty.