Jaxpointe at Saulsbury Ct Assisted Living

A revisit survey was completed on 1/15/25 or all previous deficiencies cited on 7/25/24. 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 licensure complaint, prompted by #CO32604, was completed on 7/11/23. Deficiencies were cited. Based on observation, record review and interview, the residence failed to ensure a name based criminal history report was requested, prior to hire, and conducted by the Colorado Bureau of Investigation (CBI) for three of three sample staff (#1-#3), affecting five current residents and one former resident (#6).Findings include:1. ObservationOn 7/11/23 between approximately 7:30 a.m. and 4:00 p.m., Staff #3 worked in the residence and provided care and se.. Based on observation, record review and interviews, the residence failed to update comprehensive assessments when residents' conditions changed from baseline status or at least annually, affecting one of two sample residents (#1) and one former resident (#6). (Cross-reference Q1150, Q1362 and Q2130)Findings include:1. References and Residence Policya. The residence' s care plan policy, updated 3/1/15, read in part: " Residents are reassessed at least yearly or .. Based on observation, record review, and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one of two sample residents (#1) and one former resident (#6) whose records were reviewed. (Cross reference Q2130, Q1146 and Q1150)Findings include:1. Reference and Residence PolicyAccording to the Centers for Disease Control and Preventio.. Based on record review and interview, the residence failed to develop policies and procedures to establish a fall management program, affecting five current residents and one former resident (#6).Findings include: An untitled and undated policy included in the residence' s Quality Management Program (QMP) read in part: "Prevention of falls is a top priority. The majority of residents being cared for have compromised health conditions and increased fall risks. If.. Based on record review and interview, the residence failed to ensure the care plan for each resident in the secure environment included a resident' s known behavioral expressions along with individualized approaches to be implemented and a description of how the resident will have continuous independent access to their room and protect from unwanted visitation, affecting one former resident (#6). (Cross-reference Q1362 and Q1146) Findings include: T.. Based on record review and interview, the residence failed to make available, either directly or indirectly through a resident agreement, personal services, affecting one of two sample residents (#1). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, in section two, defines "Personal Services" as those services that an assisted living residence and its staff provide for each resident including, but not l.. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, affecting five current residents and one former resident (#6).Findings include: 1. References According to Colorado Revised Statutes (2017) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs.. Based on record review and interviews, the residence failed to ensure resident records contained progress notes including information on resident status, wellbeing, any out-of-the-ordinary events and the date, time and circumstances of a resident' s death, affecting one of two sample residents (#1) and one former resident (#6). (Cross-reference Q1362 and Q1146)Findings Include:1. Residence PolicyThe residence' s Resident Record policy, updat..