BRIDGE ASSISTED LVG AT LIFE CARE CTR OF LONGMONT, THE

A revisit survey was completed on 12/29/25 for all previous deficiencies cited on 9/3/25. The facility is in compliance with all deficiencies that were cited.

A licensure survey revisit was completed on 9/3/25 for the previous deficiencies cited on 1/11/23. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event 367N11 were cited prior to the regulation revision that was implemented on 7/1/25.

A relicensure survey was completed on 9/3/25. A deficiency was cited.

Based on record review and interview, the residence failed to store resident medications in a refrigerator that does not contain food, affecting two of nine sample residents (#21, #22). Findings include:On 9/3/25 at approximately 745 a.m., the refrigerator in the residence medication room revealed food near residents' refrigerated medications. The food consisted of a bottle of water, a can of soda, and an open, partial bottle of a protein drink. The refrigerated medications included lorazepam 2 mg/ml 0.35 (0.5 mg) per syringe, two packages of Lorazepam 2 mg/ml oral concentrate for Resident #21. Additionally, there were packaged syringes of lorazepam 2 mg/ml oral concentrate for Resident #22. On 9/3/25 at approximately 7:45 a.m., Staff #14 stated regarding to the food in the refrigerator with medications, "we know we are not supposed to, but sometimes people do". On 9/3/25 at approximately 3:20 p.m., the administrator said she expected staff to not store food in the refrigerator with medications and that "they should know better".

A relicensure survey was completed on 1/11/23. Deficiencies were cited.

Based on interview and record review, the residence failed to have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization, affecting 61 current residents. Findings include:.1. Referencesa. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training" Brouhard, R., EMT (11/30/21) First Aid, 10 Basic First Aid Procedures, retrieved from: https://www.verywellhealth.com/basic-first-aid-procedures-1298578b. According to the National cardiopulmonary resuscitation (CPR) Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own direction. Our services are designed with occupational safety and health administration (OSHA), the ECC/ILCOR and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2023), Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/c. According to the American Healthcare Academy, "If a student attains a certification card from American Health Care Academy, it does not guarantee that the student is 'qualified' to perform adult, child or infant CPR/automated external defibrillator (AED), First Aid, or how to effectively act if exposed to blood (bloodborne pathogens). It is the student's responsibility to ensure that our certificate fulfills their requirements as requested by an employer/institution or state." American Healthcare Academy (2023), Terms of Service, retrieved from: https://cpraedcourse.com/legal/terms/d. According to the American Academy of CPR and First Aid, "Our certification does not guarantee that you are qualified to perform adult, child, and infant first aid. First-time CPR taker is recommended to take hands-on CPR training at a physical location. It is your responsibility to ensure that our certificate fulfills the requirements as requested by an employer, institution or state ... The American Academy of CPR and First Aid is an independent organization, our courses are written by board certified physicians and healthcare providers. We are NOT affiliated with any other organizations such as American Heart Association (AHA) or American Red Cross (ARC)." American Academy of CPR and First Aid (2009-2023), Terms of Service, retrieved from: https://www.onlinecprcertification.net/termsandservices.php 2. Personnel files and the staff schedule revealed the following:On 1/11/23 at approximately 10:00 a.m., first aid certification documentation was provided for all staff. Six of nine (#1-#3, #7-#9) staff did not have first aid certification from a nationally recognized organization. Staff #10's card was not provided. Review of the 12/28-1/11/23 staffing schedule revealed Staff #4, #5 and #6 had not worked on any of the overnight shifts (10:00 p.m. to 6:00 a.m.) and had only worked on the morning shifts (6:00 a.m. to 2:00 p.m.) and afternoon shifts (2:00 p.m. to 10:00 p.m.). Therefore, the overnight shifts were worked by staff that were not certified from a nationally recognized organization. 3. InterviewOn 1/11/23 at approximately 9:30 a.m., the resident services director (RSD) stated she was unaware the first aid certifications that Staff (#1-#3, #7-#9) had not been nationally recognized. She added the first aid certification she completed was an online course with no in-person training. On 1/11/23 at 11:00 a.m., the business office manager (BOM) stated she was unaware the first aid certifications that Staff (#1-#3, #7-#9) had not been nationally recognized. On 1/11/23 at 12:15 p.m., the administrator stated he was responsible for ensuring there was at least one CPR first aid certified staff member onsite at all times. He added he was unaware the residence was required to have a CPR or first aid certified staff member onsite at all times.

Based on record review and interview, the residence failed to have 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 61 current residents. (Cross-reference Q732)Findings include:1. References a. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (5/1/21) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 b. According to the National Health and Safety Association, "As a confident professional who has been certified many times before, you don't need to spend unnecessary time practicing on a manikin to prove your proficiency. Now you can get certified in under 30 minutes and have your card the same day." National Health and Safety Association (2023), retrieved from: https://www.cpr.io/how-it-works/c. According to the American Health Care Academy, "If a student attains a certification card from American Health Care Academy, it does not guarantee that the student is "qualified" to perform adult, child or infant CPR/AED, First Aid, or how to effectively act if exposed to blood (bloodborne pathogens). It is the student's responsibility to ensure that our certificate fulfills their requirements as requested by an employer/institution or state." American Health Care Academy Terms (2023), retrieved from: https://cpraedcourse.com/legal/terms/d. According to the National cardiopulmonary resuscitation (CPR) Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own direction. Our services are designed with occupational safety and health administration (OSHA), the ECC/ILCOR and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2023), Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/e. According to Very Well Health, "For employees required to have CPR training, OSHA (Occupational Safety and Health Association) standards specify that OSHA online-only certifications are not acceptable. Many employers, especially healthcare organizations, only accept certification from the American Red Cross or the American Heart Association. Those cannot be obtained online." Brouhard, R., EMT (4/20/22) Are Online Certifications Valid, retrieved from: https://www.verywellhealth.com/are-online-cpr-certifications-valid-1298423 2. Record Reviewa. Advanced DirectivesReview of sample residents advanced directives revealed Resident #4-#13 required CPR in the event of an emergency.b. Staff CPR certificationsThe following staff received their CPR certifications from an organization that was not nationally recognized, as follows:The resident services director on 4/27/22Staff #1 on 8/11/22Staff #2 on 10/24/22Staff #3 on 8/2/22Staff #7 on 10/21/22Staff #8 on 10/21/22Staff #9 on 10/24/22c. Staffing ScheduleThe business office manager (BOM) provided copies of staff CPR certifications. Six of nine (#1-#3, #7-#9) staff did not have CPR certification from a nationally recognized organization. Staff #10's card was not provided. Review of the 12/28-1/11/23 staffing schedule revealed Staff #4, #5 and #6 had not worked on any of the overnight shifts (10:00 p.m. to 6:00 a.m.) and had only worked on the morning shifts (6:00 a.m. to 2:00 p.m.) and afternoon shifts (2:00 p.m. to 10:00 p.m.). Therefore, the overnight shifts were worked by staff that were not certified from a nationally recognized organization. 3. InterviewsOn 1/11/23 at 9:00 a.m., the administrator was asked to provide proof of any and all staff members who were certified in CPR/Obstructed airway from a nationally recognized organization. On 1/11/23 at approximately 9:30 a.m., RSD stated she had taken the CPR/obstructed airway certification class online and had not completed an in-person or virtual skills demonstration. On 1/11/23 at approximately 10:40 a.m., Staff#11 stated she had taken the CPR/obstructed airway certification class online and had not completed an in-person or virtual skills demonstration. On 1/11/23 at approximately 11:00 a.m., the BOM stated Staff #14 took the online CPR class which did not include an in-person skills demonstration. On 1/11/23 at 12:15 p.m., administrator stated he was responsible for ensuring there was at least one CPR first aid certified staff member onsite at all times. He added he was unaware the residence was required to have a CPR or first aid certified staff member onsite at all times.

Based on observation, interview, and record review, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation) so that the information was readily available to staff at all times, affecting 61 current residents. (Cross-reference Q0736)Findings include: Observations were conducted in the residence on 1/11/23 from 7:30 a.m. to 4:30 p.m. A list of staff who had current certification in first aid or CPR from the nationally recognized organization were not posted in the residence at any time. Personnel files revealed Staff (#6-#8) were CPR and first aid certified from nationally recognized organizations. On 1/11/23 at 8:35 am., Staff #6 stated she was unaware which staff were certified in first aid or CPR.On 1/11/23 at 8:50 a.m., Staff #7 stated she was unaware which staff were certified in first aid or CPR.On 1/11/23 at 11:00 a.m., the business office manager (BOM) stated she was unaware the residence was required to maintain a list of all staff who were certified in first aid or CPR or which staff had the certifications from the nationally recognized organization. She added the resident services director (RSD) was responsible for maintaining a list of which staff had their first aid or CPR certification. On 1/11/23 at 12:15 p.m., the administrator stated he was unaware the residence was required to maintain a list of all staff who were certified in first aid or CPR. He added, he assumed all staff members were certified in first aid and CPR.

Based on record review and interviews, the residence failed to establish a fall management program which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two of three sample residents (#1-#2) with a history of falls. Specifically, Resident #1 sustained a fall without injury on 9/4/22. The residence's care plan for Resident #1 had not been updated to detail the individualized approach necessary to address Resident #1's fall risks related to documented deficits in strength and balance. Subsequently, Resident #1 sustained an additional series of falls on 11/25/22, 12/14/22 and 1/2/23 that resulted in a golf ball sized bump on the right rear side of the head, lacerations on her face and a skin tear on her left knee, laceration on the back of head and skin tear on the top of right hand. No additional individualized approached had been documented by the residence to address Resident #1's fall risk to prevent additional falls. Specifically, Resident #2 sustained a fall without injury on 12/8/22. The residence's care plan for Resident #2 had not been updated to detail the individualized approach necessary to address Resident #2's fall risks related to documented deficits in strength and balance. Subsequently, Resident #2 sustained an additional series of falls on 12/9/22, 12/17/22, 1/6/23 that resulted in pain in rib/side area, discomfort and pain in left knee. No additional individualized approached had been documented by the residence to address Resident #2's fall risk to prevent additional falls. Findings include:1. Residence policyThe residence's Fall Management policy, dated 9/1/14, read in part: "No harm to a resident as a result of a fall. The (residence) must provide a safe environment in accordance with health and safety standards. All residents must be assessed for their risk of falling during their initial assessment. All those residents identified as 'at risk' for falling must have appropriate fall prevention strategies put in place on their service plan (care plan) ... All residents must be assessed for their fall risk. Those residents identified as 'at risk' must have a fall evaluation completed; a. on admission to the (residence) b. Following any change of condition, c. Following a trend in falls- more than 3 (three) falls in 1 (one) month period, d. Biannually. Fall interventions must be documented in the resident's service plan and in the progress notes ... All staff involved in resident contact must be provided with education on fall prevention and management on a regular on ongoing basis ... " 2. Resident #1 was admitted to the residence on 1/27/22 with diagnoses including Atherosclerotic heart disease, unspecified atrial fibrillation.a. Record ReviewProgress notes for Resident #1, dated 9/4/22-1/4/23, following falls resulted in pain and injuries:On 9/4/22, Resident #1 was found on the floor in her bedroom. On 11/25/22, Resident #1 was found on the dining room floor. Resident obtained a golf ball sized bump on the right rear side of her head. On 11/27/22, Resident #1 was found on the floor in her bedroom next to her bed, near the dresser. On 12/14/22, Resident #1 fell on the toilet floor when staff went to help the resident assist toileting and change her incontinence product. Resident #1 had two lacerations on her face and a skin tear on her left knee. On 1/2/23, Resident #1 was found on the floor in her bedroom next to her bed. Laceration on the back of head and skin tear on top of right hand. Fall risk assessments for Resident #1, dated 11/30/22, 12/14/22 and 1/3/23 were reviewed and revealed the following:On 11/30/22, Resident #1 had documentation of two to three falls in the prior 90 days. The assessment read Resident #1 cognitive status was not changed, she was steady and confined to the chair. Resident #1 was frequently incontinent and needed regular assistance with toileting. Resident #1 was independent with mobility and transfers and she did not require any assistance. No interventions were noted to be implemented to prevent additional falls related to deficits in balance and strength. On 12/14/22, Resident #1 had documentation of one-two falls in the prior 90 days. The assessment read Resident #1 cognitive status was not changed, she was steady and confined to the chair. Resident #1 was frequently incontinent and needed regular assistance with toileting. Resident #1 was independent with mobility and transfers and she did not require any assistance. No interventions were noted to be implemented to prevent additional falls related to deficits in balance and strength. On 1/3/23, Resident #1 had documentation of two to three falls in the prior 90 days. The assessment read Resident #1 cognitive status was not changed, she was steady and confined to the chair. Resident #1 was frequently incontinent and needed regular assistance with toileting. Resident #1 was independent with mobility and transfers and she did not require any assistance. No interventions were noted to be implemented to prevent additional falls related to deficits in balance and strength. The care plan for Resident #1, dated 11/19/22, read Resident #1 was provided escort to meals, activities and outside services. Staff will be made aware that the resident was at the risk of fall. Resident#1 will be provided assistance with continence management during each shift. No additional updates, interventions or individualized approaches necessary to address Resident #1's fall risk related to documented deficits in strength and balance were noted in the care plan after Resident #1 had fallen on 11/27/22, 12/14/22 and 1/2/23.b. InterviewsOn 1/11/23 at 8:35 am., Staff #7 stated Resident #1 was at risk for falls. She also stated the interventions in place to mitigate falls were to ensure resident was using walker. She stated she was not aware of what the care plan read in regards to staff interventions in place to mitigate Resident #1's falls. On 1/11/23 at 3:45 p.m., the RSD stated the fall risk section in the electronic resident record was pre-populated for each resident and staff were unable to add individualized approaches or make changes. She added individualized approaches to prevent falls should be included on the care plan for Resident #1.3. Resident #2 was admitted to the residence on 4/29/21 with the diagnoses including Dementia and osteoporosis.a. Record ReviewProgress notes for Resident #2, dated 12/8/22-1/6/23, read the following falls resulted in pain and injuries:On 12/8/22, Resident #2 was found on the floor outside the nursing office. The resident services director (RSD) and Staff #13 heard the resident yelling and groaning in pain. On 12/9/22, Resident #2 was found on the dining room floor holding onto her "ribs/side area." RSD heard the resident calling out for help and RSD assisted her care staff using a gait belt. On 12/17/22, Resident #2 was found on the bedroom's floor. Resident #2 was crying in pain. 911 was called and the resident was taken to the hospital. On 1/6/23, Resident #2 appeared to have some discomfort in the left knee. The external agency stated that she might have fallen and hurt it. A fall risk assessment dated 12/19/22, read Resident #2 was a fall risk and had three or more falls in the last three months. Resident #2 behavioral and cognitive status was not changed and he was independent and ambulates without assistance. The residence's care plan for Resident #2, updated on the date on onsite survey (1/11/23) read Resident #2 had advanced dementia and required frequent reminders for safety. Qualified medication administration persons (QMAP) and care staff conducted frequent safety rounding and reported to the immediate supervisor for any concerns. However, the care plan was not updated with the individualized approaches necessary to address the resident's fall risk related to deficits in strength and balance in order to prevent further falls. b. InterviewsOn 1/11/23 at 8:02 a.m., Staff #7 stated Resident #2 had fallen many times. Staff #7 added the reason for her fall was her dog. She added Resident #2 once fell on the dog leash and added the resident's dog was no longer at the residence so the resident was no longer falling. On 1/11/23 at 8:30 a.m., Staff #6 stated Resident #2 was considered a fall risk and had a couple of falls around Christmas time. On 1/11/23 at 12:40 p.m., the resident services director (RSD) stated Resident #1 had fallen approximately four to five times in the last six months. The RSD stated she was responsible for updating the resident care plans and assessment after every fall. She stated she added post fall assessment after every fall for Resident #1 and #2 and added she did not realize that the interventions were required to be added to the care plan. On 1/11/23 at 3:45 p.m., the RSD stated the fall risk section in the electronic resident record was pre-populated for each resident and staff were unable to add individualized approaches or make changes. She added individualized approaches to prevent falls should be included on the care plan for Resident #1 and #2. On 1/11/23 at 4:05 p.m., the business office manager (BOM) stated she was aware that Resident #1 and #2 were fall risk and added RSD was in charge of developing fall risk interventions on the care plans. On 1/11/23 at approximately 4:30 p.m., the administrator stated if a resident fell and there was no injury that staff would assist the resident off the floor and notify the resident's family, practitioner and RSD. He stated an assessment and update to the care plan was required to be completed after every fall for a resident. The administrator stated the resident's electronic health record were populated automatically based on the information in the assessments and added she would expect the care plan to have been updated at the same time as the assessments. He stated Resident #1 and #2 care plans were not individualized and added staff required more training in regards to updating care plan. He stated the interventions listed on the care plans for Resident #1 and #2 included the same approaches and added the were not changed or individualized for both of the residents. He stated RSD was responsible for updating the care plan and expected RSD to fill and update the care plan with assessments after every fall.

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 2 and 7.2.3.6. Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer. (A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI). 9.1 The assisted living residence shall develop and at least annually review, all policies and procedures. At a minimum, the assisted living residence shall have policies and procedures that address the following items:(B) Resident rights;(C) Grievance procedure and complaint resolution. 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. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.