Mackenzie Place - Colorado Springs

A revisit survey was completed on 11/29/23 for all previous deficiencies cited on 6/28/23. No 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

A relicensure survey, with complaint #CO30646, was completed on 6/28/23. Deficiencies were cited. Based on interviews and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#1-#3).Findings include:1. Reference and Residence Policiesa. The residence' s medication administration policy, updated March 2022, read in part: "each resident will have a monthly medication administration record with exact (practitioner' s) orders for each prescribed medication ... the (residence) will provide the medications to a resident in the form they are prescribed."2. Resident #2 was admitted to the residence on 12/2/21, with a diagnosis of neuralgia. A written practitioner' s order, dated 5/2.. Based on observations, interviews and record reviews, the residence failed to ensure the qualified medication administration personnel (QMAP) did not perform decision making regarding PRN or "as needed" medication administration, affecting one sample resident (#1) in the secured environment who was administered PRN medication ten times in June 2023 although unable to request it.Findings include:1. References and Residence Policya. The residence' s medication services policy, updated March 2022, read in part: "unless the (practitioner) had indicated that a resident is able to identify the need for the medication at the time the order was issued, unlicensed staff shall not .. Based on record review and interview, the residence failed to ensure the house rules listed all possible actions which may have been taken by the residence if any rule was knowingly violated by a resident and failed to address marijuana usage, affecting 70 current residents.Findings include:On 6/28/23 at 9:16 a.m., an environmental tour revealed the house rules were not posted anywhere in the residence.On 6/28/23 at 9:55 a.m., the general manager (GM) placed the house rules in a publicly visible location near the residence dining room. However, the house rules did not list all possible actions which may have been taken by the residence if a resident knowingly violated the house rules. On 6/.. Based on record review and interviews, the residence failed to ensure the resident roster contained emergency contact information along with a residence diagram showing room locations, affecting 70 current residents.Findings include: On 6/28/23 at approximately 8:42 a.m., the residence' s roster was provided. However, the roster did not include emergency contact information or a residence diagram showing room locations. On 6/28/23 at 3:15 p.m., the general manager (GM) stated the resident roster she had provided was retrieved from the residence' s electronic health information system and there were no other rosters available.On 6/28/23 at 4:56 p.m., the administrator stated that.. 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 7.14.29 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 ..