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 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 the resident roster provided was the residence's only resident roster. The administrator stated he was unaware of the requirement that resident rosters needed to include emergency contact information for residents and a facility diagram that showed room locations.

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 6/28/23 at 9:18 a.m., Staff #5 stated she had never seen house rules displayed in a publicly visible location at the residence. On 6/28/23 at 9:38 a.m., the GM stated she had never seen house rules posted publicly and was not aware house rules were required to be posted. On 6/28/23 at 9:39 a.m., the memory care director (MCD) stated she was aware of the requirement for house rules to be posted and was unaware they were not. On 6/28/23 at 3:35 p.m., Resident #2 stated she had never seen house rules posted at the residence. Resident #2 further stated she was not informed of any possible actions the residence could take if any rule was knowingly violated by a resident. On 6/28/23 at 3:40 p.m., Resident #4 stated she was not aware of the house rules at the residence and acknowledged she was never informed of any possible actions the residence could take if any rule was knowingly violated by a resident. Resident #4 stated she had not seen house rules posted anywhere in the residence. On 6/28/23 at 5:01 p.m., the administrator stated he was unaware of the requirement for house rules to be placed in a publicly visible location and for house rules to include a list of actions taken by the residence for rules violated. The administrator acknowledged it was his responsibility to ensure compliance with the regulations.

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 assist a resident with PRN medication."b. Chapter VII regulations governing assisted living residences, require in part 14.9, that no medication shall be administered by a qualified medication administration person on a pro re nata (PRN) or "as needed" basis except: (B) Where the resident understands the purpose of the medication, is capable of voluntarily requesting the medication, and the assisted living residence has documentation from an authorized practitioner that the use of such medication in this manner is appropriate. 2. Resident #1 was admitted to the secured environment from assisted living on 6/7/23. A written practitioner's order, dated 6/12/23, directed the residence to administer guaifenesin 10 mL every four hours as needed for cough. The June 2023 electronic medication administration record (eMAR) read that guaifenesin was administered once by Staff #6 on 6/13/23 and nine times by Staff #4 on 6/15, 6/16, 6/20-6/24, 6/27 and 6/28/23, for a total of ten times. Both Staff #4 and #6 were QMAPs. On 6/28/23 at 8:12 a.m., Staff #4 entered Resident #1's room to wake her up and the resident and the resident coughed. On 6/28/23 at 8:14 a.m., Staff #4 went to the medication cart and dispensed Resident #1's guaifenesin which had a PRN label on it, and administered the medication to Resident #1. On 6/28/23 at 8:15 a.m., Staff #4 stated that Resident #1's external hospice nurse wanted QMAPs to administer PRN guaifenesin whenever Resident #1 coughed. Staff #4 stated since Resident #1 coughed, she administered the medication. Staff #4 further stated the reason the external hospice nurse for Resident #4 wanted her to administer guaifenesin every time Resident #1 coughed was because she was unable to request it. On 6/28/23 at 1:48 p.m., the external hospice nurse for Resident #1 stated when Resident #1 coughed, herself or another hospice nurse would go to the residence to perform an assessment and instruct staff to administer guaifenesin. The external hospice nurse stated they would prefer not to prescribe PRN medications. However, she stated residence staff were aware they needed to call a hospice nurse prior to administration for a written order to administer. On 6/28/23 at 2:16 p.m., the external hospice nurse acknowledged she had not received a telephone call on 6/28/23, the day of the onsite investigation to administer the medication. The external hospice nurse stated she expected QMAPs at the residence to notify her prior to administering PRN guaifenesin to Resident #1 so that a practitioner order could be written to administer the dose. On 6/28/23 at 2:29 p.m., contrary to what the external hospice nurse for Resident #1 stated, Staff #6 stated that the external hospice nurse for Resident #1 did not visit the resident at the residence, perform an assessment, or supervise the medication administration every time QMAPs contacted her about PRN medications. Staff #6 stated she had administered Resident #1 her PRN guaifenesin once before and was intructed by the external hospice nurse to administer the medication every time Resident #1 coughed. Staff #6 stated she had contacted the external hospice nurse when she administered the PRN medication to Resident #1 and the external hospice nurse instructed her to administer it. However there was no order written for a one time dose of guafenesin. On 6/28/23 at 2:36 p.m., a medication cart audit revealed PRN guaifenesin was stored in the secured environment medication room for Resident #1. On 6/28/23 at 2:54 p.m., Resident #1's family member stated the resident was unable to verbalize her needs due to cognitive impairment. On 6/28/23 at 4:47 p.m., the administrator stated that he was aware it was a requirement that staff could not administer as needed medications if a resident could not request it; however, he thought it was okay if it was a medication like guaifenesin and if under the direction of the external hospice nurse with a nurse assessment. On 6/28/23 at 5:26 p.m., the memory care director (MCD) stated she had relayed to staff to contact the external hospice provider or Resident #1's family member prior to administering PRN guaifenesin. The MCD was also under the impression that QMAPs could administer guaifenesin to Resident #1 if instructed by the external hospice nurse via telephone.

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 5/25/23, directed the residence to administer carbamazepine 100 mg three times daily. However, the June 2023 eMAR read the medication was discontinued on 6/9/23 in the evening without an order to discontinue the medication, for a total of 53 missed doses. On 6/28/23 at 12:21 p.m., the administrator stated he did not have a discontinue order for Resident #2's carbamazepine. On 6/28/23 at 4:49 p.m., the administrator stated he had never received a discontinue order from Resident #2's practitioner after she had slowly tapered from one medication to another and was placed on a different medication. The administrator acknowledged he should have had a discontinue order prior to the medication being discontinued from the eMAR.3. Resident #1 was admitted to the secured environment from assisted living on 6/7/23.a. LevothyroxineA written practitioner's order, dated 2/8/23, directed the residence to administer levothyroxine 0.137 mg daily. However, the June 2023 eMAR read the residence failed to administer levothyroxine on 6/13, 6/14 and 6/16/23 due to waiting on the pharmacy to deliver, for a total of three missed doses. On 6/28/23 at 5:26 p.m., the memory care director stated the medication was not administered as ordered due to the pharmacy not having delivered the medication on time. b. LactuloseA written practitioner's order, dated 4/20/23, directed the residence to administer lactulose 10 mL twice daily. However, the June 2023 electronic medication administration record (eMAR) read the medication was administered once on 6/5 and 6/6/23, for a total of two missed doses. An additional written order, dated 6/7/23, directed the residence to administer the medication once daily. On 6/28/23 at 4:49 p.m., the administrator stated a new order for lactulose was written on 6/7/23, however, staff began the new lactulose order a few days before they had the signed order. He confirmed the medication should have been administered twice daily until the new order was received on 6/7/23.4. Resident #3 was admitted to the residence on 6/5/23. A written practitioner's order, dated 5/2/23, directed the residence to administer senna 8.6-50 mg two tablets twice daily. However, the June 2023 eMAR read the residence failed to administer senna once on 6/5 and 6/6 and 6/19/23, and twice on 6/16-6/18/23 due to waiting on the pharmacy to deliver, for a total of nine missed doses. On 6/28/23 at 4:50 p.m., the administrator stated he expected the residence to ensure Resident #3's senna was in stock, and acknowledged he was unsure why the medication was out of stock for nine doses. 5. InterviewsOn 6/28/23 at 7:55 a.m., Staff #1 stated that QMAPs were responsible for ordering medication from the pharmacy that was not cycle filled. On 6/28/23 at 5:00 p.m., the administrator stated himself and QMAPs were responsible for ordering medication from the pharmacy. The administrator stated that he expected the residence to comply with practitioner's orders and ensure medications were in stock. The administrator acknowledged that medications should have been administered until the residence had an order to discontinue.

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 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. 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (B) A resident's pattern of refusal.