MAXWELL CENTER ASSISTED LIVING RESIDENCE

An administrative relicensure survey was completed on 4/1/26. No deficiencies were cited.

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 #1 worked as a qualified medication administration person (QMAP) at the residence. On 11/29/23 from approximately 10:30 a.m. until 3:00 p.m., Staff #2 worked at the residence as a QMAP. The personnel records for Staff #1 read the staff was hired on 7/26/23. The residence's name-based background check for Staff #1, dated 7/19/23, contained no criminal history report conducted by the CBI.The residence's November 2023 schedule read in part that Staff #1 worked at the residence 19 times on 11/1, 11/2, 11/5-11/8, 11/12-11/15, 11/19-11/22, 11/23, 11/27-11/29/23. The personnel records for Staff #2 read the staff was hired on 7/5/23. The residence's name-based background check for Staff #2, dated 7/19/22, contained no criminal history report conducted by the CBI.The residence's November 2023 schedule read in part that Staff #2 worked at the residence 10 times on 11/4, 11/5, 11/11, 11/12, 11/18, 11/19, 11/23, 11/25, 11/26, 11/29/23. On 11/29/23 at 2:04 p.m., the administrator stated she believed the home office of the residence conducted a criminal history check through CBI as part of other background checks. She added she was unaware that the home office had not conducted a criminal history report by the CBI. She stated she was aware of the requirement that the CBI should have conducted the criminal history check. On 11/29/23 at 2:22 p.m., the clinical residential network director stated that the home office of the residence confirmed that they had not conducted a criminal background check by CBI.

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 administered, and the resident's response to the medication, refused medication, and the reason for refusal. 2. Resident #1 was admitted to the residence on 6/3/19 with diagnoses including bipolar disorder, history of pulmonary thromboembolism, pain, muscle spasms, migraine, wheezing, and rhinitis. A written practitioner's order, dated 9/1/23, directed the residence to administer tizanidine 4 mg daily at bedtime. However, the November 2023 MAR revealed circled initials on 11/10/23 without a documented explanation. A written practitioner's order, dated 9/1/23, directed the residence to administer fluticasone propionate 50 mcg two sprays to each nostril daily. However, the November 2023 MAR revealed a blank space on 11/24/23. A written practitioner's order, dated 9/1/23, directed the residence to administer Nucynta 75 mg, one tablet every six hours. However, the November 2023 MAR revealed a blank space on 11/22/23. A written practitioner's order, dated 8/31/23, directed the residence to administer buspirone 15 mg, one tablet three times daily. However, the November 2023 MAR revealed a blank space on 11/22/23. A written practitioner's order, dated 9/1/23, directed the residence to administer Tylenol 650 mg, one tablet in the morning and two tablets in the evening. However, the November 2023 MAR revealed a blank space on 11/24/23. A written practitioner's order, dated 9/1/23, directed the residence to administer aspirin 81 mg daily. However, the November 2023 MAR revealed a blank space on 11/24/23. On 11/29/23 at approximately 3:00 p.m., the administrator stated that she expected the staff to document each medication administration after administration. She added the staff were required to document descriptions of omissions, refusals, and "as needed" medication administration outcomes. She stated that the staff should have completed the MAR and documented descriptions of exceptions. She added she was unaware that the staff had not documented in the MAR accurately, that they omitted descriptions of exceptions, and that the MARs contained blank spaces. 3. Additionally, the residence failed to ensure each QMAP accurately documented each medication administration or monitoring event at the time the event was completed and information regarding medication omissions, refusals, and resident-reported responses to medications for Resident #2.

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 11/29/23 at 1:18 p.m., a metal coffee can without a lid was in the outdoor designated smoking area and contained cigarette butts and ashes. On 11/29/23 at 3:00 p.m., the administrator stated that she was not aware that the coffee can the residence used for cigarettes was not fire resistant. She affirmed there were several smokers at the residence and that two residents used oxygen.

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 which are incomplete or unclear and obtain new orders in writing. 14.27 No stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name. 18.8 Resident records shall contain, but not be limited to, the following items: (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs;

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, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications. The 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 administered, and the resident's response to the medication, refused medication, and the reason for refusal. 2. Resident #1 was admitted to the residence on 6/3/19 with diagnoses including bipolar disorder, history of pulmonary thromboembolism, pain, muscle spasms, migraine, wheezing, and rhinitis. A written practitioner's order, dated 9/1/23, directed the residence to administer tizanidine 4 mg daily at bedtime. However, the November 2023 MAR revealed circled initials on 11/10/23 without a documented explanation. A written practitioner's order, dated 9/1/23, directed the residence to administer fluticasone propionate 50 mcg two sprays to each nostril daily. However, the November 2023 MAR revealed a blank space on 11/24/23. A written practitioner's order, dated 9/1/23, directed the residence to administer Nucynta 75 mg, one tablet every six hours. However, the November 2023 MAR revealed a blank space on 11/22/23. A written practitioner's order, dated 8/31/23, directed the residence to administer buspirone 15 mg, one tablet three times daily. However, the November 2023 MAR revealed a blank space on 11/22/23. A written practitioner's order, dated 9/1/23, directed the residence to administer Tylenol 650 mg, one tablet in the morning and two tablets in the evening. However, the November 2023 MAR revealed a blank space on 11/24/23. A written practitioner's order, dated 9/1/23, directed the residence to administer aspirin 81 mg daily. However, the November 2023 MAR revealed a blank space on 11/24/23. On 11/29/23 at approximately 3:00 p.m., the administrator stated that she expected the staff to document each medication administration after administration. She added the staff were required to document descriptions of omissions, refusals, and "as needed" medication administration outcomes. She stated that the staff should have completed the MAR and documented descriptions of exceptions. She added she was unaware that the staff had not documented in the MAR accurately, that they omitted descriptions of exceptions, and that the MARs contained blank spaces. 3. Additionally, the residence failed to ensure each QMAP accurately documented each medication administration or monitoring event at the time the event was completed and information regarding medication omissions, refusals, and resident-reported responses to medications for Resident #2.

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.