Mackenzie Place - Fort Collins

A revisit survey was completed on 1/23/25 for all previous deficiencies cited on 9/17/24. 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 relicensure survey with complaints #CO31867 and #CO37127 was completed on 9/17/24. Deficiencies were cited. Based on observation and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR) so that the information was readily available to staff at all times, affecting 39 current residents. Findings include:An environmental tour on 9/17/24 from approximately 7:00 a.m. to 9:00 a.m., revealed no evidence of a visible list of staff with current CPR and first aid certifications. On 9/17/24 at 9:18 a.m., Staff #3 stated she had not seen a list of CPR and first aid certified staff in a visible location within the residence that was readily available at all times. On 9/17/24 at approximately 4:20 p.m., the administrator stated she was aware of the requirement for the residence to place a list of staff with current cert.. Based on observation, record review, and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire for three of three sample staff (#1-#3), affecting 39 current residents.Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following i.. Based on record review and interview, the residence failed to ensure there was at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 39 current residents. Findings include:Documented CPR certifications for Staff #1 and #3 revealed CPR completion dates of 3/19/23 and 6/8/23. However, the certifications were not from a nationally recognized organization. The staff schedule, from 9/1/24 to 9/17/24, revealed the following shifts had no staff members onsite with current certification in CPR from a nationally recognized organization as follows:9/1/24 from 10:00 p.m. to 9/2/24 at 6:00 a.m.9/2/24 from 10:00 p.m. to 9/3/24 at 6:00 a.m.9/3/24 from 10:00 p.m. to 9/.. 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 7.14.31: The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence' s Quality Management Program assessment and review.18.9: The face sheet shall be updated at least annually and contain the following inf..