MACKENZIE PLACE - FORT COLLINS

SUMMARY FINDINGS:On 2/12/24 agency caregiver (1) was neglectful in assisting resident (A) with their needs due to being under the influence and acting erratically. Resident (A) resided in the memory care unit and was removed from the immediate area where agency caregiver (1) was. Client (A) was unharmed during the incident. The police and the paramedics arrived and agency caregiver (1) was transported to the hospital after admitting to misuse of prescription medications. No performance issues in caregiver (1)’s file. The facility’s investigation concluded, caregiver (1) was neglectful. Caregiver (1)’s employment was terminated and client (A) was provided with another caregiver. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 11/25/2024 · released to the public 12/2/2024.

DESCRIPTION OF OCCURRENCE: On 11/30/23, a female resident (B) in her 70s was witnessed walking behind a male resident (A) in his 60s and pushed him from behind. Resident (A) fell to the floor on his knees and elbows. Resident assistant (1) witnessed the incident. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families, ombudsman and physician. The residents were separated immediately. Resident (A) was able to get himself off the floor after being given a chair to push up from. He had red areas to his knees and elbows. Both residents had cognitive impairments. Resident (A) was able to state another resident was behind him and pushed him. Resident (B) could not recall what occurred. The facility investigation concluded resident (A)’s actions were reckless, causing resident (B) to fall to the floor and land on his knees and elbows. To help prevent a recurrence, staff will monitor both residents every 30 minutes. A one-to-one oversight was implemented for resident (B) and their spouse will provide frequent visits to help reduce behaviors. Resident (B) will also be receiving additional hospice support to assist with behavior and redirection techniques. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

DESCRIPTION OF OCCURRENCE: On 5/7/23, staff member (1) heard yelling coming from a resident's room. Upon entering the room, staff observed resident (B) striking resident (A) across the face. She made a grunting noise after immediately being struck on the face. Both residents were in their 80s and had cognitive impairments. Resident (B) had gotten angry at resident (A) when he could not find something in the room. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman, Adult Protective Services and physician. Staff member (1) separated both residents and brought resident (A) to the dining room in line of sight by staff. No visible injuries were seen; however, resident (A) was tearful and confused. Comfort was provided. Resident (B) had difficulty speaking and was given a pen and a paper. He drew two objects on the paper: a watch and a case. This staff member went to look for these objects and found them. Resident (B) raised both of his thumbs up indicating these were the items he had been searching for in the room. Staff handed the items to the resident (B) and noted resident (B) did not recall hitting resident (A). Safety checks were started to monitor the residents. The facility substantiated an allegation of resident (B) striking resident (A) when he got upset. Staff was asked to ensure resident (B) had his watch on during the day and that his case was visible on his table. Safety monitoring remained in place. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 2/12/2024 · released to the public 2/12/2024.

DESCRIPTION OF OCCURRENCE: On 4/23/23, there was a report of resident (A) ingesting another resident (B)'s medications (an antipsychotic and enzyme). A qualified medication administration person (QMAP1) placed resident (B)'s medications in juice and set the cup down in front of resident (B). The QMAP (1) left and resident (A) proceeded to take resident (B)'s juice and drank it. Resident (A) had a cognitive impairment and required staff oversight. QMAP (1) failed to follow medication standards of practice by ensuring resident (B) consumed the medications prior to walking away. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family, ombudsman and physician. QMAP (1) recognized the error and notified a manager. Management removed QMAP (1) from the duties of administering medications and suspended them. Staff reported resident (A) was drowsy and slept most of the day. Staff monitoring occurred for resident (A)’s sedation every hour for the next 24-hours as instructed by the physician. Staff said her vital signs stayed within normal parameters. The family showed up to stay with the resident (A) as well for additional monitoring. The following morning, staff reported the resident returned to baseline. QMAP (1) stated they had gotten up from the table to answer the doorbell when this happened and acknowledged leaving the medications unattended. Another staff reported they witnessed resident (A) consume the juice but had not been aware of medications being in the juice. Review of QMAP (1)'s personnel record indicated they had received previous counseling on the medication administration policy for medications errors. The facility investigation concluded QMAP (1) left medications unattended and did not following medication standards of practice for resident safety. A decision was made to terminate the staff member's employment on 4/26/23. To help prevent a recurrence, all QMAPs were re-trained on Medication Services policy. Management requested the QMAPs sign an acknowledgment form indicating they received and understood the information. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 2/5/2024 · released to the public 2/5/2024.

DESCRIPTION OF OCCURRENCE: On 3/4/23 a female resident (A) in her 80s went to the front desk for the independent living side of the facility. The front desk could not identify the resident immediately and/or when the resident (A) had gone out the front door. Two staff members went to look for resident (A) and could not find her. The police and family were called and assisted with the search. Resident (A) was found by the police about an hour later walking on a nearby street. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. Resident (A) was returned to the facility and not found to be in any distress. Resident (A) has a diagnosis of dementia. A family member stayed with resident (A) for the remainder of the night. The facility investigation concluded resident (A) was confused, and required more oversight. The front desk personnel were educated on front desk policy and procedures. To help prevent a recurrence, during the day time hours resident (A) is taken to the memory care for day programming. During the night the staff will conduct 30 minute safety checks on her until the resident was moved to the memory care unit on 3/10/23. The facility will continue to work on processes and systems to prevent a recurrence. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 8/7/2023 · released to the public 8/14/2023.