JAXPOINTE AT FLOWER COURT ASSISTED LIVING

A licensure complaint, prompted by #CO42221, was completed on 5/28/26. Deficiencies were cited.

Based on record review and interviews, the residence failed to comply with all occurrence reporting required by state law and shall follow the reporting procedures, including investigation of an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations, as well as providing documentation of the investigation affecting one sample resident who eloped from the secure environment (#1). Findings include:1. Record review Resident #1 was admitted to the residence on 4/22/26 with a diagnosis of major neurocognitive disorder due to Alzheimer ' s disease with mood disturbance. An incident report dated 4/30/26 read that staff had observed Resident #1 lying in her bed at 1:45 p.m. However, when staff did their rounds between 2:00 p.m. and 2:30 p.m., they found Resident #1 was no longer in her bed. The staff completed a sweep of the residence and contacted the administrative assistant (AA). The AA arrived to search for Resident #1 and was contacted by law enforcement during the search. Resident #1 had been located at a nearby store, and the individuals who found her had called law enforcement. The resident's family was called by law enforcement and returned Resident #1 to the residence. The residence noted the resident had no injuries; however, her lips were chapped. A law enforcement report, dated 5/1/26, stated that local law enforcement was telephoned to a local store on 4/30/26 at 2:45 p.m. regarding a welfare check on Resident #1. The law enforcement officer identified that Resident #1's lips were bleeding, and she was distraught when found by the officer. When the resident's family member arrived to pick up the resident from local law enforcement, the report stated that Resident #1 was cold and dehydrated, with cracked lips, and "had the appearance of someone who had been outside for an extended period of time." Resident #1 was disoriented and actively crying. When the officer contacted the AA, she advised that she had been driving around for approximately 30 minutes looking for the resident but had not yet called the missing person event into law enforcement. Due to Resident #1's cognitive decline and having left a secure environment unattended, the officer was required to make a report to Adult Protective Services. Resident #1 was returned to the residence by family members and was noted in the law enforcement report not to have any physical markings of concern. On 5/28/26 at approximately 8:00 a.m., an investigation and documentation of the reported occurrence was requested; however, not received. 2. InterviewOn 5/28/26 at 12:30 p.m., the administrative assistant (AA) acknowledged that the residence only did an internal investigation that was done right after the elopement. She also stated the residence did not do a thorough investigation with documentation of the findings and report the occurrence to the department as required. The AA stated she believed a formal investigation should have been completed to ensure Resident #1 ' s safety and well-being.

Based on observation, interview, and record review, the residence failed to provide protective oversight, affecting one sample resident (#1). Specifically, Resident #1 eloped from the residence's secure environment on 4/30/26. It was reported that she walked about one mile, and when law enforcement found her she was cold, emotional, dehydrated, and her lips were severely chapped and bleeding. The residence last laid eyes on the resident at approximately 1:45 p.m., however, the resident was found at a store a mile away at 2:45 p.m. Findings include:1. Resident #1 was admitted to the residence on 4/22/26 with a diagnosis of major neurocognitive disorder due to Alzheimer ' s disease with mood disturbance. Resident #1's care plan, updated 4/30/26, revealed that the residence had included that the resident was "a flight risk" and interventions were put into place for staff to keep Resident #1 in line of sight at all times and to accompany her when in the backyard to ensure she did not go out alone. An incident report dated 4/30/26 read that staff had observed Resident #1 lying in her bed at 1:45 p.m. However, when staff did their rounds between 2:00 p.m. and 2:30 p.m., they found Resident #1 was no longer in her bed. The staff completed a sweep of the residence and contacted the administrative assistant (AA). The AA arrived to search for Resident #1 and was contacted by law enforcement during the search. Resident #1 had been located at a nearby store, and the individuals who found her had called law enforcement. The resident's family was called by law enforcement and returned Resident #1 to the residence. The residence noted the resident had no injuries; however, her lips were chapped. A law enforcement report, dated 5/1/26, stated that local law enforcement was telephoned to a local store on 4/30/26 at 2:45 p.m. regarding a welfare check on Resident #1. The law enforcement officer identified that Resident #1's lips were bleeding, and she was distraught when found by the officer. When the resident's family member arrived to pick up the resident from local law enforcement, the report stated that Resident #1 was cold and dehydrated, with cracked lips, and "had the appearance of someone who had been outside for an extended period of time." Resident #1 was disoriented and actively crying. When the officer contacted the AA, she advised that she had been driving around for approximately 30 minutes looking for the resident but had not yet called the missing person event into law enforcement. Due to Resident #1's cognitive decline and having left a secure environment unattended, the officer was required to make a report to Adult Protective Services. Resident #1 was returned to the residence by family members and was noted in the law enforcement report not to have any physical markings of concern. On 5/7/26 at 10:55 a.m., the gate on the left side of the residence ' s backyard was observed to be open to the street and was unlocked. Residents had open access to the backyard from the dining room ' s door and there were no alarms or surveillance to supervise or monitor the residents ' activities in the backyard to prevent and/or minimize the risk for residents ' elopement from the secure environment. It was further observed that the maintenance director was outside removing branches from a storm the prior day. On 5/7/26 at 2:20 p.m., the gate was observed to be closed again. On 5/7/26 at 2:30 p.m., two large trash cans on the street side of the residence's gate were observed on the right side of the building. In addition, during the investigation, it was observed that the outdoor furniture was close to the backyard fences. The furniture was movable and could be used to climb over the fence to the outside of the secure environment. On 5/28/26 from 8:30 a.m. to 3:00 p.m., six chairs were placed alongside the exterior fence; the furniture had not been moved. On 5/7/26 at 11:15 a.m., during an interview, Staff #1 revealed that she could not locate Resident #1 on 4/30/26 in her room when Staff #1 was counting residents ' headcount for dinner preparation around 2:00 p.m. She said she checked with Staff #8, who had been working with Staff #1 that day, to see if Staff #8 knew where Resident #1 was. Staff #1 said that when they did not find the resident, she called the AA and informed her of the resident's absence. On 5/7/26 at 11:30 a.m., the AA was interviewed. She said she was on call on 4/30/26 and drove to the residence after receiving the report of missing Resident #1. The AA said she arrived at the residence about 10 minutes after receiving a call from Staff #1 at 2:55 p.m. She said she drove towards the nearby park, looking for the resident, after she completed searching the residence. She said a family member of the resident called her at 3:20 p.m. and said the resident was with law enforcement and that the family member would bring her back to the residence. The AA said a young couple had found the resident at a nearby store about 1.5 miles away from the residence and called law enforcement. She said the resident ' s family member was a dispatch officer and recognized the resident ' s name; so, the resident ' s family members brought her back to the residence from the law enforcement office. The AA said the resident was cold, emotional, and confused upon her return to the residence. The AA said the resident was able to tell her that she had left in an effort to take a walk but had lost her way while taking her walk. She said the resident was checked for any injuries or skin issues; her lips needed lip moisturizing due to dry and chapped lips . The AA said that Resident #1 had been athletic and a bicycling champion in her 50s, and that the staff had underestimated her physical ability at the time of the initial admission assessment. She stated "We had an assumption, after realizing how strong she is, that she jumped over the fence, stepping on the latch of the backyard gate. We are almost sure she did not exit from the front door." She stated their internal investigation (incident report) revealed that the only way Resident #1 could exit the residence was through the left-side gate. She said they moved the trash cans away from the gate after the incident. However, the trash cans were observed at the residence's right side gate on 5/7/26. The AA said the residence had begun implementing interventions for Resident #1 and had conducted a root cause analysis. The AA said it had been determined, based on the resident's prior social history from the family, that she had enjoyed walking her dog, so the AA began bringing her own dog every morning and allowed Resident #1 to walk the dog with her. She said this had seemed to help alleviate some of Resident #1's desire to leave. Resident #1 was also the only ambulatory resident who was at risk for elopement. On 5/7/26, during an interview with Staff # 3 at 1:51 p.m., she said that Resident #1 often tried to exit by attempting to climb over the fence, push open the gate, and call out to get the neighbor's attention to facilitate an exit from the backyard. She said the resident yelled expletives at her and other staff when they tried to redirect her. Staff #3 said that the resident walked "all over the back yard from corner to corner."The AA was interviewed again on 5/7/26 at approximately 2:00 p.m. and stated that the gate had been observed open at 10:55 a.m. because the maintenance director had been outside removing branches that had broken due to a recent snowstorm. She also said that the trash cans had been observed on the residence's right side of the gate because the day of the survey was trash collection day. On 5/7/26, during an interview with Staff #8 at 3:45 p.m., she said she had been worried about Resident #1 on 4/30/26 (when the incident happened) because she paced back and forth and asked visitors to give her a ride. She said the resident moved very quickly. Staff #8 said that the resident had been attentive towards the door and tried to exit when she saw cars pass by the residence through the window on 4/30/26. On 5/7/26 between 12:00 p.m. and 3:45 p.m., all the residence caregiving staff who had not been interviewed in person onsite (Staff #2, #4, #5, #6, and #7) were contacted via telephone. All staff confirmed they were aware of the changes to Resident #1's supervision, including line of sight and accompaniment when in the backyard.

Based on observations, record review, and interviews, the residence failed to supervise the outdoor area and ensure the fence or enclosure around the perimeter of the outdoor area was no less than six (6) feet in height and constructed to reduce the risk of residents wandering or eloping from the area, affecting seven current residents. Findings include:1. Record ReviewResidence Safety and Risk Management Policy, dated 5/1/2009, revised 3/1/25, reads, "8. Security: Lock exterior doors, monitor alarms, control visitor access, and ensure proper lighting and surveillance in outdoor areas." The review of Resident #1's record revealed she was diagnosed with a major neurocognitive disorder due to Alzheimer ' s disease with mood disturbance. She was admitted to the residence on 4/22/26. The resident ' s care plan with updates dated 4/22/26 and 4/30/26, read that Resident #1 was an elopement risk. The care plan further identified that upon admission, the resident was physically active and enjoyed fitness and dancing. 2. ObservationsOn 5/7/26 at 10:55 a.m., the gate on the left side of the residence ' s backyard was observed to be open to the street, and was unlocked. In addition, the length of the gate ' s fence was measured at 5 '10" with a large opening, approximately five inches in height and five inches in width, midway to the top of the fence where the lock was located. Residents had open access to the backyard from the dining room door, and there were no alarms or surveillance to supervise or monitor the residents ' activities in the backyard to prevent and/or minimize the risk for residents ' elopement from the secure environment. In addition, there were 5 chairs lined up by the left side fence in the backyard, and one chair on the back fence. All chairs were located along the edge of the fence. On 5/28/26 from 8:30 a.m. to 3:00 p.m., six chairs were placed alongside the exterior fence; the furniture had not been moved. 3. InterviewsOn 5/7/26 at 11:30 a.m., the AA stated, "We had an assumption, after realizing how strong she is, that she jumped over the fence, stepping on the latch of the backyard gate. We are almost sure she did not exit from the front door." She stated their internal investigation (incident report) revealed that the only way Resident #1 could exit the residence was through the left-side gate. She said they moved the trash cans away from the gate after the incident. However, the trash cans were observed at the residence's right side gate on 5/7/26. On 5/7/26, during an interview with Staff #3 at 1:51 p.m., she said that Resident #1 often tried to exit by attempting to climb over the fence, push open the gate, and call out to get the neighbor's attention in an attempt to facilitate an exit from the backyard. She said the resident yelled expletives at her and other staff when they tried to redirect her. Staff #3 said that the resident walked "all over the back yard from corner to corner". On 5/7/26, Staff #8 stated that the resident had been attentive towards the door and tried to exit when she saw cars pass by the residence through the window on 4/30/26. On 5/7/26 at approximately 2:30 p.m., during an interview with the AA, it was discussed that the measurements of the length of the fences show that they vary in length; the left side gate fences measured 5 ' 10" and the left side fences (wall) measured 5 ' 11". The AA acknowledged the concern about the length of the fences and said she noticed the surveyor was carefully measuring the length of the fences and observing the backyard setup.

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. 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment.

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 12/23/24. 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 #CO36035, was completed on 12/23/24. Deficiencies were cited.

Based on record review and interview the residence failed to annually review their resident rights policy, affecting seven current residents. Findings include:On 12/23/24 at 7:45 a.m., the residence resident rights policy was requested, however, it did not contain all required elements in accordance with part 13.1. On 12/23/24 at 3:32 p.m., the administrator reported the residence resident rights policy was created in 2009 and reviewed between six and 12 months prior to the onsite investigation. He reported being unaware that the policy did not contain all the required elements and expected the policy to meet the regulations.

Based on record review and interview, the residence failed to have documentation indicating evidence that staff successfully completed an accredited food safety course, affecting seven current residents. Findings include:On 12/23/24 at approximately 7:45 a.m., documentation of food safety training from a recognized food safety agency for Staff #1-#7 was requested. However, it was not provided for Staff #2-#7. On 12/23/24 at 2:48 p.m., Staff #1 reported they had completed their food safety training. They reported Staff #2, #3, and #7 assisted with food preparation for main meals and all staff assisted with serving meals, snacks, and drinks. On 12/23/24 at 2:50 p.m., Staff #4 reported they assisted with food preparation and food serving. They reported not having a food safety training certification and were unaware of the requirement to have it. On 12/23/24 at 3:40 p.m., the administrator reported the overnight staff and the staff who was the team lead during the day shift did most of the meal preparation; however, all staff helped with food preparation. The administrator reported being unaware of this requirement and expected staff to have completed the required food safety training.

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 7.7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (B) Dementia Training Requirements(3) Initial Training: Each assisted living residence is responsible for ensuring that all direct-care staff members are trained in dementia diseases and related disabilities. (a) Initial training shall be available to direct-care staff at no cost to them(b) The training shall be competency-based and culturally-competent and shall include a minimum of four hours of training in dementia topics including the following content:(i) Dementia diseases and related disabilities;(ii) Person-centered care of residents with dementia; (iii) Care planning for residents with dementia; (iv) Activities of daily living for residents with dementia; and (v) Dementia-related behaviors and communication. (c) For direct-care staff members already employed prior to January 1, 2024, the initial training must be completed as soon as practical, but no later than 120 days after January 1, 2024, unless an exception, as described in sub-part 7.8(B)(4)(a), applies. (d) For direct-care staff members hired or providing care on or after January 1, 2024, the initial training must be completed as soon as practical, but no later than 120 days after the start of employment or the provision of direct-care services, unless an exception, as described in sub-part 7.8(B)(4)(B), applies. 16.21 Refrigerated foods opened or prepared and not used within twenty-four (24) hours must be marked with a "use by" or "discard by" date. The "use by" or "discard by" date is seven (7) calendar days following opening or preparation. The seven (7) days cannot surpass the manufacturer's expiration date for the product or its ingredients or seven (7) days since the date any of the ingredients in the food were opened or prepared. This requirement does not apply to commercially prepared condiments and dressings.

A revisit survey was completed on 8/8/23 for all previous deficiencies cited on 12/14/22. The facility is in compliance with all deficiencies 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