Assurance Assisted Living Home at Killarney LLC

A revisit survey was completed on 12/11/25 for all previous deficiencies cited on 6/30/25. 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 with complaint #CO39848 was completed on 6/30/25. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure that each staff member met the dementia training requirements in 7.9(B), affecting six current residents.Findings include:Personnel files for Staff #1 and #3 provided by the administrator designee, revealed no evidence that the staff members met the dementia training requirements in part 7.9(B).Review of resident records revealed Resident #1 and #4 had diagnoses of dementia. On 6/30/25 at 4:45 p.m., the administrator designee stated Staff #1 and #3 had not completed the required dementia training in 7.9(B) since she was unaware of the requirement. On 6/30/25 at 4:46 p.m., the house manager stated she was aware of the requirement for dementia training. She stated there was a dementia trainer who had provid.. Based on observation, record review and interviews, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting six current residents. Findings include:1. ObservationOn 6/30/25 at 10:27 a.m., an environmental tour revealed the residence' s designated smoking area and fire resistant disposal container less than 25 feet of the residence' s back door. 2. Record ReviewA list of current smokers was requested from the administrator. Smoking evaluations were provided for Resident #2 and #3. 3. InterviewsOn 6/30/25 at 3:45 p.m., Staff #2 stated Resident #2 and #3 smoked on the outdoor patio, which was less than 25 feet from the back door of the residence. On 6/30/25 at 4:49 p.m., the administrator designee stated she w.. Based on observation, record review, and interview, the residence failed to ensure the medication administration record reflected the correct dosage, and that each qualified medication administration person (QMAP) documented accurate information on the medication administration record (MAR), affecting two of three sample residents whose medications were reviewed (#1, #3). Findings include:Resident #3 was admitted to the residence on 1/31/24. A written practitioner' s order, dated 3/12/25, directed the residence to administer Risperdol 2 mg in the evening. However, the June 2025 MAR read the medication was administered at bedtime twice from 6/1-6/29/25. Additionally, staff #1 signed off that Risperdol 2 mg was administered in the evening of 6/30/25 which had not yet oc.. 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 andcompleteness of the medication administration records, controlled substance list, medication errorreports, 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 livingresidence ' s Quality Management Program assessment and review." ..

A recertification survey with complaint #CO39847 was completed on 6/30/25. Deficiencies were cited. Based on observation, record review, and interviews, the facility (residence) failed to comply with the restrictions on smoking near entryways outlined in the Colorado Clean Indoor Air Act (CCIAA), affecting six current members (residents).Findings include:1. ObservationOn 6/30/25 at 10:27 a.m., an environmental tour revealed the residence' s designated smoking area and fire resistant disposal container less than 25 feet of the residence' s back door. 2. Record ReviewA list of current smokers was requested from the administrator. Smoking evaluations were provided for Resident #2 and #3. 3. InterviewsOn 6/30/25 at 3:45 p.m., Staff #2 stated Resident #2 and #3 smoked on the outdoor patio, which was less than 25 feet from the back door of the residence. On 6/30/25 at 4:49 p.m., the administrator designee stated she was aware of the requirement for the designated smoking area to be over 25 feet from entryways and would have expected compliance with the Colorado Clean Indoor Air Act. Based on record review and interview, the (facility) residence failed to ensure each qualified medication administration person (QMAP) accurately recorded all medications administered, affecting two of three sample (members) residents whose medications were reviewed (#1, #3.)Findings include:Resident #3 was admitted to the residence on 1/31/24. A written practitioner' s order, dated 3/12/25, directed the residence to administer Risperdol 2 mg in the evening. However, the June 2025 MAR read the medication was administered at bedtime twice from 6/1-6/29/25. Additionally, staff #1 signed off that Risperdol 2 mg was administered in the evening of 6/30/25 which had not yet occurred, for a total of 30 inaccurately documented doses. On 6/30/25 at 2:41 p.m., Staff #1 stated she only administered Risperdol 2 mg once and was unsure why it was duplicated on the June 2025 MAR. She stated that she had accidentally signed off for the evening 6/30/25 although she had not yet administered the medication.On 6/30/25 at 4:44 p.m., the house manager stated she was responsible for updating MARs and should have caught that Risperdol 2 mg was duplicated on the MAR.On 6/30/25 at approximately 4:45 p.m., the administrator designee stated she would have expected staff to only sign off once on the June 2025 MAR and at the time the admin..

A revisit survey was completed on 11/9/23 for all previous deficiencies cited on 3/30/23. 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 11/9/23 for all previous deficiencies cited on 3/30/23. 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