Jaxpointe at Holland St Assisted Living

A revisit survey was completed on 2/27/25 for all previous deficiencies cited on 10/22/24. 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 was completed on 10/22/24. Deficiencies were cited. Based on observation, record review and interview, the residence failed to reassess residents for their continued need for a secure environment every six months or when the resident' s condition changed from baseline status affecting two of two sample residents (#1, #3.)Findings include:Resident #1On 10/22/24 at 8:30 a.m., Resident #1 was observed in her room sitting in a geri chair recliner that she was not able to self propel. Observations throughout the day revealed Resident #1 was not able to move herself.A doctor' s visit form, dated 10/2/24 read the reason for the visit was to evaluate the resident for external hospice services for Resident #1. The visit form also read her diet was downgraded from mechanical soft to puree.The resident agreement signed on 8/17/20 by the power of attorney for Resident #1 read in part "Assessments will be completed on each resident prior to the admission to the secured environment." "Re-assesments must be completed within 10 days of a significant change in the medical or physical condition of the .. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records (MAR), affecting seven current residents. Findings include:On 10/22/24 at 9:15 a.m., documentation of the residence' s quarterly medication audits were requested but none were provided.On 10/22/24 at approximately 12:00 p.m., the director stated she did not complete medication audits at all. She stated she was aware of the requirement to complete medication audits on a quarterly basis.On 10/22/24 at approximately 1:00 p.m., the executive director acknowledged there were no quarterly medication cart audits and he had not participated in the audit. 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 7.8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident' s representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers along with care coordination arrangements; and(F) Identify formal, planned, and informal ..