Kraft Home INC

A revisit survey was completed on 3/23/26 for all previous deficiencies cited on 9/2/25. 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 recertification survey with complaint #CO39856 was completed on 9/2/25. Deficiencies were cited. Based on observation, record review, and interviews, the facility (residence) failed to provide training to employees prior to having unsupervised contact with members (residents) for one (#1) staff for six current residents.Findings Include:Observations of the residence on 9/8/25 from 8:30 a.m. to 5:30 p.m., revealed Staff #1 working independently with residents.Staff #1' s personnel file read that the residence hired the staff member on 7/1/18; however, the file contained no dementia training.On 9/2/25 at approximately 8:40 a.m., Staff #1 stated that .. Based on observations and interviews, the facility (residence) failed to provide an outdoor area accessible to members (residents) without staff assistance that is well maintained for six current residents.Findings Include:An environmental tour on 9/2/25 at 12:30 p.m., revealed a five-inch drop in the concrete sidewalk next to the designated smoking area; additionally, a section of the privacy fence was unstable and leaning away from its supports, appearing to have been struck by a fallen tree.On 9/2/25 at approximately 12:30 p.m., Resident #1 stated that the drop off in the sidewalk n.. Based on record review and interviews, the facility (residence) failed to conduct assessment prior to admission and whenever a significant change in care needs, affecting two of three sample residents (#2 and #7). (Cross-reference B0760)Findings Include:1. Record ReviewResident #7 was admitted to the residence on 4/16/25 with a diagnosis of alcohol intoxication, pulmonary emphysema, and bilateral carpal tunnel syndrome. The record for Resident #7 contained no evidence of a pre-admission assessment completed by the residence.There was no evidence of an asses.. Based on record review and interviews, the facility (residence) failed to document changes in members' (residents' ) condition and action taken because of changes, affecting one sample resident ( #7). (Cross-reference B1710)Findings Include:Resident #7 was admitted to the residence on 4/16/25.On 9/2/25 at 8:40 a.m., Staff #1 stated that when Resident #7 was at the hospital from 8/21-8/29/25 a bag of unidentified medication was found in Resident #7' s room when completing housekeeping tasks. Staff #1 stated she reported it to the administrator; however, she did not docu.. Based on record review and interviews, the facility (residence) failed to maintain a personnel record which contained documentation all trainings and of criminal background check for one (#1) sample staff, affecting six current members (residents).Findings Include:The administrator' s personnel file revealed no evidence of a current CPR/First-Aid certification.Staff #1' s personnel file read that the residence hired the staff member on 7/1/18; however, the file contained no evidence of CPR/First-Aid certification or the results of a background check.On 9/2/2.. Based on records review and interviews, the facility (residence) failed to provide sufficient support to members (residents) in the use of medications, affecting three of three sample residents (#2, #6 and #7).Findings Include:1. Record reviewa. Inaccurate MAR informationA record review of the August 2025 MAR for Resident #6 revealed that four medications (bupropion HCL XL, clopidogrel, donepezil, and fluticasone prop) were marked as "DC" on the MAR. However, there was no discontinued date included on or from the practitioner' s order.Similar deficient practice occu..

A relicensure survey with complaint #CO39855 was completed on 9/2/25. Deficiencies were cited. Based on interviews and record review, the residence failed to document any out-of-the-ordinary event before the end of the shift, affecting one sample resident (#7). (Cross-reference U1010, U1146)Findings Include:Resident #7 was ad.. Based on observation and interviews, the residence failed to maintain the grounds free of hazards, affecting six current residents.Findings Include:An environmental tour on 9/2/25 at 12:30 p.m., revealed a five-inch drop in the c.. Based on observation, record review and interviews, the residence failed to ensure a direct-care staff member received required dementia training for one sample staff (#1), affecting six current residents.Findings Include:Observ.. Based on record review and interview, the residence failed to complete a pre-admission assessment of a resident' s physical, mental, and social needs; cultural, religious, and activity needs; preferences; and capacity for self-care, af.. Based on record review and interview, the residence failed to count jointly, document results, and sign all controlled substances by two individuals at the beginning and end of each shift, for three of three controlled substance counts f.. Based on record review and interviews, the residence failed to have an involuntary discharge grievance policy, affecting six current residents.Findings Include:On 9/2/25 at approximately 8:45 a.m., the residence' s involuntary dis.. Based on record review and interviews, the residence failed to have written policies and procedures regarding visitation rights, affecting six current residents.Findings Include:On 9/2/25 at approximately 8:45 a.m., the residenc.. Based on record review and interviews, the residence failed to maintain a separate sheet of controlled substances, which contained the date and time administered, name of authorized practitioner, and the quantity of the controlle.. Based on record review and interviews, the residence failed to maintain documentation of cardio-pulmonary resuscitation and first aid (CPR/First-Aid) certification, and the results of a background check in the personnel file fo.. Based on record review and interviews, the residence failed to update each resident' s comprehensive assessment whenever there was a condition change from baseline status, affecting two of three sample residents (#2 and #7). (C.. Based on record review and interviews, the residence medication administration record (MAR) failed to maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their si.. 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 a..

8.7408.A.12 Written Plans to Address Emergencies (a) An emergency can be defined as an unforeseen situation that may endanger the lives of Members and/or staff, as well as disrupt for a short time the normal operations within a setting or Agency. (b) Emergencies can include, but are not limited to: (i) Medical Emergencies (ii) Public Health Emergencies (iii) Fire (iv) Natural Disasters (c) Each HCBS Provider Agency shall have written policies and procedures to address emergencies, unless otherwise specified within service regulations. (i) Plans should include how the agency prepares for loss of staff, various emergencies, back up plans, protocols, etc. should any staff be affected. (ii) Day Habilitation services shall have written plans to address emergencies regardless of service location or type of program. Based on record reviews and interviews, the facility (residence) failed to have complete written plans to address emergencies as specified within service regulations from 6 CCR 1011-1 Chapter 7 Part 10 Emergency Prepare.. 8.7506.F.5.b Alternative Care Facilities shall provide an outdoor area accessible to Members without staff assistance that is well maintained, facilitates community gatherings, and is appropriately equipped for the population served.Based on observations, record reviews, and interviews, the facility (residence) failed to provide an outdoor area accessible to members (residents) that was well maintained, affecting six current residents. (Cross-reference A0132)Findings include:On 4/9/25 at 7:40 a.m., an environmental tour of the residence revealed hallways on the main, second, and basement floors cluttered with extraneous materials that constrain emergency egress, including a four-wheeled walker observed stored at the base of the indoor stairway, preventing any safe use of the stairway. Step ladders, mops, extension cords, dirty laundry, discarded mattresses, fans, space heaters, appliances, as well as general refuse items and general household items piled under tables, in corners, and spaces normally not meant for s.. A certification complaint, prompted by #CO39774, was completed on 4/10/25. Deficiencies were cited. Based on observations, record reviews, and interviews, the facility (residence) failed to afford to each member (resident) the opportunity to live and receive services in a clean and safe environment, affecting six current residents. (Cross-reference S0001 & S0002)Specifically, the residence failed to ensure compliance with county fire codes. Failed to ensure cleaning compounds and other hazardous substances were stored in a location sufficiently secure to deny access to confused residents. Failed to comply with state oxygen handling and storage requirements. Failure to prohibit smoking in areas where oxygen was stored and used. Failed to have effective written policies and procedures for the control and eradication of insects and other pests. As well as failed to store pesticides away from resident areas, and only allow properly trained staff to apply pesticides.Findings include:1. ReferencesChapter 3 of the International Fire Code (IFC) governing general building requirements, part 315.3 storage in buildings requires storag..