Duncan-Hart House

A certification complaint, prompted by # CO35763, was completed on 4/25/24. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to discharge within 30 days, any participant (resident), who exhibited behavior that disrupted the safety, health, and social needs of the home and was consistently disorientated to time, person and place to such a degree they posed a danger to self or others, affecting one former resident (#1).Findings include: 1. References and Residence Policiesa. Chapter VII regulations governing a.. Based on observation and interview, the facility (residence) failed to ensure participants (residents) had unrestricted access to all common areas, affecting 13 current residents and one former resident (#1). Findings include:1. Residence Policy The residence' s undated resident rights policy read in part, "Participants had the right to full use of the assisted living residence common areas in compliance with the documented house rules." 2. Observati.. Based on observation and interview, the facility (residence) failed to ensure that participants (residents) had access to nutritious food and beverages at all times, affecting 13 current residents.Findings include:1. Residence PolicyThe residence' s Hydration of Residents policy, dated 7/1/16, read in part that "fresh water is available to (residents) at all times."The residence' s undated house rules read in part, "Three meals and two snacks are provided daily. It is the (re.. Based on observation, interview and record review, the facility (residence) failed to observe participants' (residents' ) rights to communication with staff that was respectful and in a dignified manner, affecting 13 current residents and one former resident (#1).Specifically, the staff treated Former Resident #1 with disrespect throughout February and March 2024. Staff #4, Staff #5, and Confidential Residents #2, #4, #8, and #9 stated Staff #1-#3, the administrative as.. Based on observations and interview, the setting failed to ensure that individuals could access food preparation and storage areas, choose their own seats, and choose their company (or lack thereof), affecting 13 current participants (residents) and one former resident (#1).Findings Include:1. Residence Policy The facility' s (residence' s) undated house rules read in part, "Three meals and two snacks are provided daily. It is the resident' s responsibility to be present for.. Based on record review and interview, the agency (residence) failed to thoroughly document the required information when modifying rights, affecting 13 current participants (residents) and one former resident (#1). Findings include:1. References10 CCR 2505-10, part 8.484.2.E, defines "Informed Consent" as the informed, freely given, written agreement of the individual (or, if authorized, their guardian or other legally authorized representative) to a Rights .. Based on record review and interview, the facility (residence) failed to ensure care plans for participants (residents) contained required information, affecting 13 current residents and one former resident (#1). Findings include:1. References10 CCR 2505-10, part 8.484.2.E, defines "Informed Consent" as the informed, freely given, written agreement of the individual (or, if authorized, their guardian or other legally authorized representative) to a Rights ..

A licensure complaint, prompted by #CO35762, was completed on 4/25/24. Deficiencies were cited. Based on interview and record review, the residence failed to report suspected caretaker neglect to law enforcement within 24 hours of discovery, affecting one former resident (#1). (Cross-reference S430, S1322, S1324, S1410, S2110)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residencies, part 2.12, defines caretaker neglect as neglect that occurred when adequate food, clothing, shelter, psy.. Based on observation, interview, and record review, the residence failed to discharge residents who were a danger to themselves or others and required a higher level of care, affecting one former resident (#1). (Cross-reference S1324, S1410)Findings include: 1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences defines "Discharge" as termination of the resident agreement and the resident' s permanent departure fro.. Based on observation, interview, and record review, the residence failed to treat the residents with dignity and respect and protect them from verbal, physical, and emotional abuse, humiliation, intimidation, or punishment, affecting all current residents and one former resident (#1). Specifically, the staff treated Former Resident #1 with disrespect throughout February and March 2024. Staff #4, Staff #5, and Confidential Residents #2, #4, #8, and #9 stat.. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one former resident (#1) and four current confidential residents (#3, #4, #7, and #8). (Cross-reference S410, S1322, S1324, S1410, S2110)Findings include:Reference and Residence Policya. According to the Occurrence Reporting Manual, dated May 2018, "Any occurrence involving neglect of a patient or resident is a reportable occurrence." A def.. Based on record review and interview, the residence failed to investigate an allegation of verbal abuse of a resident in accordance with Part 5.3 and its written policy, affecting one former resident (#1) and four current confidential residents (#3, #4, #7, #8). (Cross-reference S410, S430, S1324, S1410)Findings include: 1. Residence PolicyThe residence' s Abuse and Neglect policy, dated 7/1/16, read in part that "the residence had a ' zero-tolerance' .. Based on record review and interview, the residence failed to observe a resident' s right to be free from neglect, affecting one Former Resident (#1). (Cross-reference S1320, S1322, S1334, S1336, S1338)Findings include:1. References and Residence Policiesa. Chapter VII regulations governing assisted living residencies, part 2.12, defines "caretaker neglect" as neglect that occurred when adequate food, clothing, shelter, psychological care, physical care.. Based on record review and interview, the residence failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community, or in accordance with resident needs, preferences, and plans of care, affecting one confidential resident (#4) and one former resident (#1).Findings include:1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences, part 17.1 requires the residence to .. 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 7.6.8 The administrator, or individual appointed as an interim administrator, shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(A) Man..

A revisit survey was completed on 4/16/24 for all previous deficiencies cited on 12/14/23. 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 4/16/24 for all previous deficiencies cited on 12/14/23. 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 recertification survey was completed on 12/14/23. Deficiencies were cited. Based on observation and interview the residence (facility) failed to be an environment that maintained a home-like quality and feel for the residents (participants) at all times, affecting 16 current residents.Findings include:1. ObservationsOn 12/14/23 starting at approximately 8:00 a.m., all of the residents sat quietly at the dining room tables. Staff #5 stood behind a kitchen counter that was open to the dining room, and she called out Resident #1' s name. Resident #1 approached the kitchen counter in the front of all the residents in the dining room; Staff #5 dispensed and administered Resident #1' s medications. Because one of Resident #1' s medications required that it dissolve under her tongue, Staff #1 instructed her to sit back down at a dining room table before she was able to leave the dining room. Staff #5 then called out the first name of Resident #4 (whose first name was alphabetically right after Resident #1' s first name out of all the residents' names). Resident #4 approached the same kitchen counter in the fro.. Based on record review and interview, the residence (facility) failed to ensure care plans for residents (participants) contained required information, affecting two of three sample residents (#1, #2).Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.9, defines a "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual' s need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual' s needs. In order to deliver person-centered care, the care plan shall take into account the resident' s preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill.b. The residence' s care plan policy, dated 7/1/16, read in part that the residence developed and implemented a care plan for each resident in order to monitor and oversee th.. 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 8.400.8.495.6(H)(2) Alternative Care Facility Providers shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII and XXIV, Medication Administration Regulations.

A relicensure survey was completed on 12/14/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each resident care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, as well as identify all external providers along with care coordination arrangements, affecting two of three sample residents (#1, #2).Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.9, defines a "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual' s need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual' s needs. In order to deliver person-centered care, the care.. Based on interview and record review, the residence failed to have at least one member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization such as the American Red Cross, the American Heart Association, National Safety Council, or American Safety and Health Institute, affecting 16 current residents.Findings include:1. References and Residence Policya. 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 rec.. Based on interview and record review, the residence failed to have at least one member onsite at all times who had current certification in first aid from a nationally recognized organization such as the American Red Cross, the American Heart Association, National Safety Council, or American Safety and Health Institute, affecting 16 current residents.Findings include:1. Reference and Residence Policya. 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." VeryWell Health (6/23/23) First Aid Instructions for 10 Medical Emergencies, retriev.. 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 7.6.8 The administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(B) Organizing and directing the assisted living residence' s ongoing functions including physical maintenance7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable8.4 Staff shall be sufficient in number to help residents needing or potentially needing assistance, consider..