Hyland Hills Senior Living

A licensure survey revisit was completed on 12/3/24 for the previous deficiencies cited on 6/13/24. Deficiencies were cited. Based on observation, record reviews, and interviews the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting 27 current residents in the secure environment.This deficiency was cited previously during a state licensure survey on 6/13/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence policyThe residence' s Alarmed Door for Locked Memory Unit policy, dated September 2024, read in part: "As part of the security system in this locked memory unit, all the doors leading to the outside are alarmed/coded and/or fobbed doors."2. ObservationOn 12/3/24 at 7:48 a.m., the secured environment of the residence had a fobbed door that led to the secure outdoor courtyard; the door was locked and only staff were able to open the door with a fob.On 12/3/24 at 9:46 a.m., the secure outdoor courtyard door was locked, and no residents were outside.On 12/3/24 at 11:48 a.m., the secure outdoor courtyard door was locked, and no residents were outside.3. Record ReviewOn 12/3/24, a document dated 12/3/24 at 12:54 p.m. showed a service part titled "Wall Reader w/LCDU 6334 (Visionllne Remote Ctrl w/o GW Freight Out" had been .. Based on record review, and interview, the residence failed to re-assess residents to determine their continued need for a secure environment every six months and whenever the resident' s condition changed from baseline status, affecting five of six sample residents (#1, #3, #4, #7 and #9).This deficiency was cited previously during a state licensure survey on 6/13/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s Resident Assessment policy, dated September 2024, read in part: "Resident assessments to be completed every 6 months at minimum and with a significant change for all residents who reside within a secured unit."2. Resident #1 was admitted to the residence on 6/28/22, with essential (primary) hypertension and chronic obstructive pulmonary disease.A care plan dated 8/21/24, read in part Resident #1 had short-term memory impairment and required some redirection and reminding from others.A document titled Placement Consultation, dated 3/30/24, and signed by a practitioner, read in part that the resident "needs management of activities of daily living (ADLs), wander risk and oxygen (O2) management."No additional documentation was provided to demonstrate t..

A licensure complaint, prompted by #CO37273, was completed on 12/3/24. No deficiencies were cited.

A licensure survey was completed on 6/13/24. Deficiencies were cited. Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy affecting 128 current residents. Findings Include:1. Residence PolicyThe residence' s discharge policy, dated March 2023, read in part: When a current resident was either voluntarily or involuntarily discharged, the resid.. Based on interviews and record review, the residence failed to have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization, affecting 128 current residents. Findings include:1. Residence policyThe residence' s Staffing policy, dated March 2023, read in part: "The community .. Based on observation and interview, the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting 19 current residents in the secure environment.Findings include:1. Residence policyThe residence' s Alarmed Door for Locked Memory Unit.. Based on observation, interview, and record review, the residence failed to develop and implement a visitation policy that described any restriction or limitation necessary to ensure the health and safety of residents, staff, and visitors, affecting 128 current residents. Findings include:During the on-site visit on 6/13/24 from 7:00 a.m. to approximately.. Based on observation, interview, and record review, the residence failed to develop and implement a visitation policy that described any restriction or limitation necessary to ensure the health and safety of residents, staff, and visitors, affecting 128 current residents. Findings include:During the on-site visit on 6/13/24 from 7:00 a.m. to approximately.. Based on observation, interview, and record review, the residence failed to implement a fall management program affecting two of two sample residents (#2, #6).Specifically, Resident #2 with a diagnosis of dementia had 11 falls within 35 days. On 5/7/24 the residence updated the care plan for Resident #2; however, Resident #2 sustained 10 fa.. Based on record review and interview, the residence failed to complete a comprehensive assessment whenever a resident' s condition changed from baseline status, affecting two of two sample residents (#6 and #7).Findings include:1. Residence policya. The residence' s Practitioner Assessment policy, dated March 2023, read in part: "It is th.. Based on record review, and interview, the residence failed to re-assess residents to determine their continued need for a secure environment every six months and whenever the resident' s condition changed from baseline status, affecting three of three residents sample residents (#1, #2,#4).Findings include:1. Residence PolicyThe residence ' s .. 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 7.14.21 The assisted living residence shall be responsible for complying with authorized practi..

A licensure complaint, prompted by #CO30269, was completed on 2/7/23. Deficiencies were cited.A change of ownership occurred on 10/17/22. Based on record review and interview, the residence failed to ensure a newly hired administrator met requirements related to supervising the delivery of personal care and services to residents, affecting 72 current residents.Findings include:1. Record ReviewOn 2/7/23 the department' s database read the administrator had been the administrator since 10/17/22.The administrator provided her resume, which revealed the administrator did not met requirements for newly hired administrators. 2. InterviewsOn 2/7/23 at 9:15 a.m., the administrator stated that prior to becoming the residence administrator, she had worked for the residence as a sales director since 2011. The administrator confirmed she had not had at least one year supervising the delivery of personal care services that included activities of daily living, prior to hire as the administrator. The administrator also confirmed she had not met any of the alternative requirements, so as to be qualified to be the administrator. On 2/7/23 at 11:00 a.m., the regional director stated he had been unaware of requirements for administrators, beyond a background check and administrator training, when the administrator was hired for the administrator position. Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 72 current residents.Findings include: 1. Referencesa. The Ninth Amended State Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response, dated 10/11/22, required residences to:-Maintain a COVID-19 vaccination and treatment plan as outlined in CDPHE Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidance. The plan must be readily available for review by county and state disease control staff and state health facility inspectors.-Report to the department information pertaining to their available resources to respond to the COVID-19 pandemic. Items that may be reported include, but are not limited to, residence bed capacity, supply of personal protective equipment and available staffing for the facilities. The department will provide the reporting platforms and the form and format for submission of the required information, which may be modified as the response to this pandemic evolves. Facilities must adhere to reporting requirements as specified in the Assisted Living and Group Ho..