Maxwell Center Assisted Living Residence

A revisit survey was completed on 3/6/24 for all previous deficiencies cited on 11/29/23. 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 3/6/24 for all previous deficiencies cited on 11/29/23. 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 relicensure survey was completed on 11/29/23. 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 two of two sample staff (#1-#2), affecting nine current residents.Findings include:The residence' s Background Check policy, dated 9/14/23, read in part that the residence' s home office conducted background checks to comply with regulatory agencies to provide a safe and secure environment for all employees. Further, the policy defined CBI as the Colorado Bureau of Investigation. The home office maintained CBI results in personnel files for five years, which were then disposed of per the residence' s home office policy.On 11/29/23 from approximately 8:00 a.m. until 9:00 a.m., Staff #.. Based on observation, record review, and interview, the residence failed to have a fire-resistant waste disposal container in the designated outdoor smoking area, affecting nine current residents. Findings include:The residence' s undated Smoking policy read in part that the residence asked the residents to place their cigarette butts in the established trash cans. On 11/29/23 at 9:00 a.m., Resident #3 stated that he smoked in the designated outdoor area and placed his cigarette butts in a coffee can.On 11/29/23 at 9:05 a.m., Resident #1 stated that all smokers smoked in the designated outdoor area and placed their cigarette butts in a coffee can.On 11/29/23 at 9:18 a.m., Resident #2 stated that she smoked in the designated outdoor smoking area and placed her cigarettes in a coffee can.On 11/29/2.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the administration was completed and failed to document information regarding medication omissions, refusals, and resident-reported responses to medications for each resident on the medication administration record (MAR), affecting two of three sample residents (#1-#2).1. Residence PolicyThe residence' s undated Medication Administration policy read in part that residence staff were required to record all medication administration after the administration. Further, staff was required to document on the back of the appropriate MAR when a medication was unavailable, "as needed" medication was admi.. 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 7.12.5 The assisted living residence shall have a policy and procedure regarding when a practitioner' s assessment of a resident is appropriate. At a minimum, the assisted living residence shall contact the resident' s primary practitioner when any of the following circumstances occur and follow the practitioner' s recommendation regarding further action.(A) The resident experiences a significant change in their baseline status.14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders whi..

A recertification survey was completed on 11/29/23. A deficiency was cited. Based on record review and interview, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations, affecting two of three sample participants (residents) (#1-#2).Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 14.29, requires that all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident' s room location, any known allergies, and the name and telephone number of the resident' s authorized practitioner.(A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.(B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.(C) Each qualified medication administration person, nu.. 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 Medical Assistance Section 8.400 Long Term Care, Nursing Facility Care, Adult Day Care Services.8.484.4.A.2.a Residents have the right to dignity and privacy, including in their living/sleeping units. This right to privacy includes the following criteria:a. Individuals must have a key or key code to their home.