Decatur West Personal Care Facility

A life safety code survey, prompted by #CO39740, was completed on 4/15/2025. Two deficiencies were cited. The facility is a two (3) story, Type V (111) wood frame structure with a basement and licensed for Thirty-two (32) residents. The facility has a National Fire Protection Association (NFPA) 13 automatic fire suppression system. This survey, conducted on April 15, 2025, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities. Based on observation and an interview, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for fire alarm installation. The facility failures had the potential to affect all occupants of the building.Findings include:Cross reference to A0001 for observation and interview related to failures to follow procedures for fire panel replacement. Based on observation and staff interviews, it was determined that the facility failed to install a fire alarm system in accordance with Life Safety Code 101 and NFPA 72. The deficient practice affected all smoke compartments. During an interview and observations with the administrator and building owner, it was noted that a new fire panel had been installed without proper plans or a permit from the Division of Fire Prevention and Control.NFPA 101.9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.NFPA 72.1.2.3 This Code establishes minimum required levels of performance, extent of redundancy, and quality of installation but does not establish the only methods by which these requirements are to be achieved.The deficient practice could affect all smoke zones, all residents, and an indeterminable number of staff and visitors. The administrator discussed the deficient items during the exit conference.

A relicensure survey with complaint #CO30941 was completed on 5/30/23. Deficiencies were cited. Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting two of three sample residents of which medications were reviewed (#2, #3). (Cross-reference Q1514)Findings include: 1. Residence Policy The residence' s undated Medication and Medication Administration policy read in part: "The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a .. Based on record review and interview, the administrator failed to be responsible for ensuring the residence' s infection control officer received required training, affecting 29 current residents.Findings include:1. ReferencesChapter II regulations governing assisted living residences, part 12.2.2 Infection Control Officer, requires the residence to have an infection control officer (ICO) and to ensure the ICO completes training as follows:- Complete an infection prevention and control training from a nationally-recognized provider within two (2) weeks of appointment/designati.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP), nurse, or practitioner accurately documented in the medication administration record (MAR), affecting three of three sample residents of which medications were reviewed (#2-#4). (Cross-reference Q1514) Findings include: 1. Residence Policy The residence' s undated Medication and Medication Administration policy read in part: "All prescribed and PRN (as-needed) medications shall be listed and recorded on a (MAR) which contains the name and date of birth .. Based on record review and interview, the residence failed to ensure each resident had the right to refuse medications, affecting one current resident (#3). Findings include: 1. Residence Policy The residence' s undated Medication and Medication Administration policy read in part: "Each resident shall have the right to refuse medications." 2. Record ReviewResident #3 was admitted to the residence on 1/26/11 with a diagnosis of schizoaffective disorder. A typed note in the residence' s medication administration record (MAR) book read "(Residen.. Based on record review and interview, the residence failed to ensure that the resident' s authorized practitioner was notified of a resident' s pattern of refusal, affecting one sample resident (#4). Findings include: 1. ReferenceThe residence' s undated Medication and Medication Administration policy read in part: "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." 2. Record reviewResident #4 was admitted to the residence on 4/6/02 with a diagnosis .. Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, quarterly, affecting 28 current residents who were administered medications by staff. (Cross-reference Q1468 and Q1510) Findings include: The residence' s undated Medication and Medication Administration policy read in part: "The administrator and the Q..

A recertification survey with complaint #CO30942 was completed on 5/30/23. A deficiency was cited. Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting 28 current residents, administered medications by the facility. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.16 requires that each resident has the right to refuse medications.a. Residence Policy The residence' s undated Medication and Medication Administration policy read in part: "Each resident shall have the right to refuse medications." b. Resident #3 was admitted to the residence on 1/26/11 with a diagnosis of schizoaffective disorder. A typed note in the residence' s medication administration record (MAR) book read "(Resident #3) is (sic) court ordered to take his meds. Please watch him very closely to make sure he takes all prescribed medications. If he refuses, cheeks, or hides any medication report it immediately." The residence' s MAR book contained a court order, which read the residence was required to administer medication to Resident #3. The residence' s May 2023 MAR for Resident #3 read he had not refused any medications.c. During interviews with four administrative staff members, discrepancies arose regarding resident rights and court orders, as follows: On 5/30/23 at 10:06 a.m., Staff #1 stated Resident #3 could not refuse his medications because he was court ordered to take them. She added if he did not take his medications, staff were to call a manager. On 5/30/23 at 10:16 a.m., Resident #3 stated on 5/28/23, that he did not want to take his medications, and described a recent incident where a staff member "tracked me down to take them, and I was told if I did not take them, they are going to put me in jail." Resident #3 stated he did not want to be on any medications and did not want to be under a court order. On 5/30/23 at approximately 10:40 a.m., the assistant administrator stated residents had the right to refuse medications, except with court order. However, she a..