BALFOUR AT LONGMONT

A revisit survey was completed on 7/10/26 for all previous deficiencies cited on 2/18/26. The facility is in compliance with all regulations surveyed.

An administrative relicensure survey was completed on 5/19/26. No deficiencies were cited. A change of ownership occurred on 4/6/26.

A licensure complaint, prompted by #CO42002 was completed on 4/20/26. No deficiencies were cited.

A licensure complaint, prompted by #CO41704 was completed on 3/18/26. No deficiencies were cited.

A complaint survey, prompted by #CO41571 and #CO40316 was completed on 2/18/26. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure personal care workers and their supervisors were trained by appropriately skilled professionals and evaluated for competency prior to providing personal services requiring specialized techniques (sit-to-stand transfer lift), affecting one of three sample residents (#1). Findings include:1. ObservationOn 2/18/26 at 7:48 am, a sit-to-stand device was present/used in the secured environment for resident transfers, indicating residents required assistance with specialized equipment beyond general personal care and activities of daily living. The sit-to-stand was located in Resident #1's room. 2. Record ReviewThe residence provided a trianing log documenting education on "Sit to Stand" provided by the Health and Service Director (HSD) and the Rehab Director on 10/11/25. Record review showed the log included multiple staff signatures; however, none of the staff interviewed and working in the secure environment on 2/18/26 were documented as attending the sit-to-stand training on the provided log. In addition, the residence did not provide documentation showing the interviewed staff had been evaluated for competency prior to performing sit-to-stand transfers. The care plan for Resident #2 dated 8/18/25 indicated the resident required staff assistance using a sit-to-stand device for transfers to and from the wheelchair, bed, and toilet daily. 3. InterviewsOn 2/18/26 at 1:51 p.m., the HSD stated the sit-to-stand training "happens with the therapy team," and a training was held in October 2025, and another was scheduled for the end of the month. She stated external hospice also provided training and the physical therapy company maintains documentation. She further stated staff hired after October 2025 had not attended the prior training and that quarterly training was delayed. On 2/18/26 at 12:25 p.m., Confidential Staff# 1 stated staff were not provided sit-to-stand training. On 2/18/26 at 1:30 p.m., LPN #1, stated she had her own sit-to-stand training but did not recall receiving sit-to-stand training provided by the residence. On 2/18/26 at 12:15 p.m., Confidential Staff #2 stated staff were not trained on sit-to-stand devices.

Based on observation, record review and interviews, the residence failed to ensure a devices that facilitate a resident's well-being and/or independence may be used if the resident is able to remove the device to allow for normal movement affecting two of two sample residents (#7 and #8) who used a bed cane. Findings include. 1. Resident #7 was admitted to the residence on 11/5/23 with diagnoses including dementia.a. ObservationOn 2/18/26 at approximately 7:45 a.m. during the onsite complaint survey, it was observed there was a bedside cane bolted into to Resident #7's bed. b. Record Review On 2/18/26 review of Resident #7 record revealed no orders for the use of bed canes, further record review revealed no record or mention of the use of bed canes in Resident #7's care plan dated 1/18/26. A written practitioner order, dated 2/18/26 (date of the onsite), read in part "Patient requires the use of a bed cane for safety with transfers in and out of bed."2. Resident #8 was admitted to the residence on 3/11/25 with diagnoses including mixed hyperlipidemia.a. ObservationOn 2/18/26 at approximately 7:55 a.m. during the onsite complaint survey, it was observed there was a bedside cane bolted into to Resident #8's bed.b. Record ReviewOn 2/18/26 review of Resident #8 record revealed no orders for the use of bed canes, further record review revealed no record or mention of the use of bed canes in Resident #7's care plan dated 1/18/26. A written practitioner order, dated 2/18/26 (date of the onsite), read in part "Patient requires the use of a bed cane for safety with transfers in and out of bed."c. InterviewsOn 2/18/26 at approximately 1:55 p.m., the HSD stated either the physical therapists (PT) and/or occupational therapists (OT) ordered or requested bed canes along with providers or external hospice. She stated Resident #7 and #8's family members brought them in and they were bolted into place. She further stated bed canes should be documented in their care plans, however, could not confirm if the bed canes were documented or not. The HSD concluded that she was aware that PT and/or OT must place the order, however she did not know the practitioner was required to order them, that the bed canes were required to be care planned and ensure residents were able to remove the device to allow for normal movement. She confirmed neither Resident #7 or #8 would be able to remove the bed cane independently.

Based on observation, interview, and record review, the residence failed to ensure the residents had the right to be free from restraint, affecting two of four residents (#2, #4). 1. ObservationOn 2/18/2026 at approximately 7:40 a.m., the surveyor observed Resident #2 and Resident #4 in their beds with large blankets, towels, pillows and sheets rolled and stuffed into the edges of the bed sheets around both sides of them in a manner that limited their ability to move freely and prevented normal movement. Resident #2 and #4 were not able to get out of bed when requested by the surveyor due to the barrier restraint. 2. InterviewsOn 2/18/26 at 7:40 a.m. the licensed practical nurser (LPN) #2 stated the night shift performed the restraint practice so residents "won't move and fall at night."On 2/18/26 at 1:50 p.m. the health and services director (HSD) stated the residents were high fall-risk with a history of falls, and acknowledged the practice was not part of their care plan. She stated the residence "probably should not have done that," but believed it was done to prevent falls since the residents were unable to get out of bed independently with the barriers in place. 3. Record ReviewRecord review did not show evidence of evaluations, orders, or care-planned interventions supporting the use of rolled blankets as barriers for Resident #2 and Resident #4, and the residence did not provide evidence the residents were able to remove the device to allow for normal movement.

Based on record review and interviews, the residence failed to ensure no medication shall be administered by a qualified medication administration personnel (QMAP) on a PRN (as needed) basis, affecting two of three residents (#5 and #6). Findings include:1. Resident #5 was admitted on 3/9/23 with diagnoses including senile degeneration of the brain. Progress notes documented the resident required PRN medications based on staff observation of grimacing/pain and agitation. An assessment dated 10/10/25 read in part the resident had increased confusion and required full staff assistance with regular redirection and/or reorientation.a. MorphineA practitioner's order dated 1/26/26 directed the residence to administer morphine sulfate oral solution 100 mg/5mL 0.25 mL every four hours as needed for pain. The January and February 2026 medication administration record (MAR) read the medication was administered by a QMAP as follows:1/28/26 at 12:58 p.m. 1/28/26 at 5:48 p.m. 2/12/16 at 5:47 p.m. 2/17/16 at 11:07 a.m.b. LorazepamA practitioner order dated 1/26/26, directed the residence to administer lorazepam 2 mg/mL 0.25 mL every 4 hours as needed for anxiety, agitation or insomnia. The January and February 2026 MAR read the medication was administered by a qualified medication administration personnel QMAP as follows:1/28/26 at 5:48 p.m. 2/6/26 at 11:43 a.m. and 3:45 p.m. 2/12/26 at 5:47 p.m.c. TylenolA practitioner order dated 1/26/26, directed the residence to administer Tylenol 500 mg two tablets every four hours as needed for pain/fever. 1/28/26 at 10:03 a.m. The January 2026 MAR read the medication was administered by a QMAP on 2/16/26.2. Resident #6 was admitted to the residency on 12/5/23 with diagnoses including Alzheimer's disease/dementia. An assessment dated 11/10/25, read in part the resident had increased confusion and required full staff assistance with regular redirection and/or reorientation. The January 2026 MAR dated 1/14/26 included an entry indicating the resident was unable to reliably report pain due to cognitive impairment and language difficulties.a. LorazepamA practitioner order dated 1/28/26, directed the residence to administer lorazepam 0.5 mg every 6 hours as needed, however staff was required to contact external hospice for approval before administering the medication. The February 2026 MAR read the medication was administered by a QMAP as follows:2/2/26 at 11:40 a.m. 2/17/26 at 12:31 p.m.b. AcetaminophenA practitioner order dated 1/28/26, directed the residence to administer acetaminophen 325 mg two tablets every four hours as needed for pain. The February 2026 MAR read the medication was administered by a QMAP on 2/16/26 at 9:46 a.m. On 2/18/26 at 12:28 p.m., Confidential Staff #1 and #2 stated QMAPs were required to administer PRNs to residents that resided in the secure environment unit. They confirmed the residents did not understand the purpose of the medications and were not capable of voluntarily asking for the medications mentioned above. On 2/18/26 at 1:51 p.m., the health and services director (HSD) stated the residence did not receive orders from external hospice every time a PRN was administered to a resident with cognitive impairment in the secure environment. She stated she was a licensed practical nurse and told QMAPs when it was okay to administer PRNs. She also stated staff knew residents required PRNs if the resident appeared in pain, agitated, yelled out, moaned, or grimaced. The HSD confirmed the residents did not understand the purpose of the medications and were not capable of voluntarily asking for the medications mentioned above.

Based on record review and interview, the residence failed to ensure qualified medication administration personnel (QMAP) did not assess residents or use judgment regarding medication effects when administering PRN (as needed) medications, affecting two of two residents (Cross-reference U1526). Findings include:1. Resident #5 was admitted on 3/9/23 with diagnoses including senile degeneration of the brain. Progress notes documented the resident required PRN medications based on staff observation of grimacing/pain and agitation.a. MorphineA practitioner's order dated 1/26/26, directed the residence to administer morphine sulfate oral solution 100 mg/5mL 0.25 mL every four hours as needed for pain. The January and February 2026 medication administration record (MAR) read the medication was administered by a QMAP as follows:1/28/26 at 12:58 p.m. 1/28/26 at 5:48 p.m. 2/12/16 at 5:47 p.m. 2/17/16 at 11:07 a.m. Additionally, after the administration of PRN medications, the QMAP was required to assess the medication's effectiveness and document it in the MAR. b. LorazepamA practitioner order dated 1/26/26, directed the residence to administer lorazepam 2 mg/mL 0.25 mL every 4 hours as needed for anxiety, agitation or insomnia..The January and February 2026 MAR read the medication was administered by a qualified medication administration personnel QMAP as follows:1/28/26 at 5:48 p.m. 2/6/26 at 11:43 a.m. and 3:45 p.m. 2/12/26 at 5:47 p.m. Additionally, after the administration of PRN medications, the QMAP was required to assess the medication's effectiveness and document it in the MAR. c. TylenolA practitioner order dated 1/26/26, directed the residence to administer Tylenol 500 mg two tablets every four hours as needed for pain/fever. 1/28/26 at 10:03 a.m. The January 2026 MAR read the medication was administered by a QMAP on 2/16/26. Additionally, after the administration of PRN medications, the QMAP was required to assess the medication's effectiveness and document it in the MAR. 2. Resident #6 was admitted to the residency on 12/5/23 with diagnoses including Alzheimer ' s disease/dementia. An assessment dated 11/10/25, read in part the resident had increased confusion and required full staff assistance with regular redirection and/or reorientation. The January 2026 MAR dated 1/14/26 included an entry indicating the resident was unable to reliably report pain due to cognitive impairment and language difficulties.a. LorazepamA practitioner order dated 9/20/24, directed the residence to administer lorazepam 0.5 mg every 6 hours as needed, however staff was required to contact external hospice for approval before administering the medicationThe February 2026 MAR read the medication was administered by a QMAP as follows:2/2/26 at 11:40 a.m. 2/17/26 at 12:31 p.m. Additionally, after the administration of PRN medications, the QMAP was required to assess the medication's effectiveness and document it in the MAR. b. AcetaminophenA practitioner order dated 5/20/24, directed the residence to administer acetaminophen 325 mg two tablets every four hours as needed for pain. The February 2026 MAR read the medication was administered by a QMAP on 2/16/26 at 9:46 a.m. Additionally, after the administration of PRN medications, the QMAP was required to assess the medication's effectiveness and document it in the MAR. On 2/18/26 at 12:28 p.m., Confidential Staff #1 and #2 stated QMAPs were required to administer PRNs to residents that resided in the secure environment then assess the medication's effectiveness. On 2/18/26 at 1:51 p.m., the health and services director stated QMAPs were directed to document PRN effectiveness, which required evaluation and judgment regarding medication effect.

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 11/13/24. 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 #CO34757, #CO32521, and #CO38265 was completed on 11/13/24. Deficiencies were cited.

Based on record review and interview, the residence failed to contact a resident's primary practitioner when the resident sustains an injury or accident, experiences a significant change in their baseline status, affecting two former residents (#11, #13). (Cross-reference S1192)Findings include:1. Former Resident #13 was admitted to the residence on 10/27/23. A progress note in Former Resident #13's record, dated 11/2/24, read at approximately 9:00 p.m. Former Resident #13 was on the floor lying on his left side in the doorway to his bathroom. Former Resident #13 was "conscious but incomprehensible" and took four staff members to move him from the floor to his feet. Former Resident #13 was confused, agitated, unable to sit down, had an elevated blood pressure and temperature. Another progress note in Former Resident #13's record, dated 11/3/24, read at approximately 7:00 a.m. Former Resident #13 was moaning and grimacing when staff assisted him with care. Emergency medical services were notified and arrived and required three staff to assist Former Resident #13 required onto the gurney. Former Resident #13's neck was placed in a soft collar. 2. During the onsite visits on 11/12 and 11/13/24 similar deficient practice was found for Former Resident #11.3. InterviewsOn 11/13/24 at 11:11 a.m., Staff #5 said Former Resident #13 fell the day before he was sent out to the emergency department for evaluation. He added, "In retrospect we should have sent him out that night ... he appeared to be in a lot of pain but getting him comfortable was one of our goals."On 11/13/24 at approximately 1:30 p.m., the administrator said she expected staff to send out Former Resident #11 and Former Resident #13 the same day they fell and not the next day.

Based on record review and interview, the residence failed to ensure staff evaluated a resident who had fallen to determine if the resident could be assisted in a safe manner, such as when the resident had no pain, or there was no change from baseline, affecting one former resident (#13). (Cross-reference S1130)Findings include: 1. Former Resident #13 was admitted to the residence on 10/27/23 with a diagnosis of Alzheimer's disease. An incident report, dated 11/2/24, read in part: Former Resident #13 was found lying in the doorway to the bathroom. Former Resident #13 was conscious but was incomprehensible. Former Resident #13 was assisted by Staff #5 and three other unknown staff from the floor to their feet. Former Resident #13 was highly confused and agitated, stating "Wait, wait, stop!" for any movement at all. Staff #5 and three other unknown staff continued assisting Former Resident #13 to his feet. 2. InterviewsOn 11/13/24 at 10:55 a.m., Staff #5 said staff should have to refrain from assisting to lift a resident from the floor if the resident said to stop, was incomprehensible or needed the assistance of three staff to physically lift them. Staff #5 said when a resident had pain while being assisted by staff off the floor, staff were to call the practitioner immediately for further direction with care. On 11/13/24 at 1:30 p.m., the administrator said that the staff should not have continued lifting Former Resident #13 after Former Resident #13 said to stop.

Based on record review and interview, the residence failed to administer or prepare only medications that were authorized by a practitioner. (Cross-reference S1568)Findings Include:1. Resident #12 was admitted to the residence on 1/8/21 with diagnoses of hypertensive heart disease and unspecified atrial fibrillation. A written practitioner ' s order, dated 1/19/24, directed the residence to hold Eliquis 5 mg for one week and start aspirin 81 mg for six days then change to Eliquis 2.5 mg twice daily on 1/26/24. "A medication administration record (MAR) for January 2024 directed staff to hold eliquis 5 mg per practitioner's orders for one week and then start Eliquis 2.5 mg. A staff education document, dated 1/20/24, read in part that the nurse administered Eliquis 5 mg to Resident #12 after the residence received a written order to hold the medication for five days. An observation note, dated 1/20/24, read that the nurse notified Resident #12's family member of a medication error in which the nurse administered Eliquis and aspirin to Resident #12 at the same time. 2. InterviewOn 11/13/24 at 7:15 a.m., the health and wellness director (HWD) stated that the nurse restarted Eliquis because she misinterpreted when the residence was supposed to start administering Eliquis and when to stop administering aspirin. 3. Similar deficient practice was found with Residents #1, #2, and #11.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting two of eight current residents (#1, #3). (Cross-reference S1530)Findings Include:1. Resident #3 was admitted to the residence on 4/18/23. A written practitioner's order, dated 9/23/24, directed the residence to administer atorvastatin 80 mg once daily. However, the November 2024 medication administration record (MAR) read the medication was not available and staff did not administer it on 11/4 and 11/5/24, for a total of two missed doses. 2. During the onsite visits on 11/12 and 11/13/24, similar deficient practice was found for Resident #1.3. InterviewsOn 11/14/24 at approximately 1:30 p.m., the administrator said she expected the residence to administer medications according to the practitioner's orders and not run out of stock. On 11/14/24 at approximately 4:30 p.m., the vice president of health and wellness acknowledged Resident #1 and #3's medications were not available and not administered, as required.

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 7.7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows:(A) The assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics:(b) Relevant emergency contact numbers,(f) Practitioner assessment,(g) Serious illness injury, and/or death of a resident.(5) Reporting requirements, including occurrence reporting procedures within the facility;(8) Where to immediately locate a resident's advance directive; and(9) An overview of the assisted living residence's policies and procedures and how to access them for reference. 7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows:(B) Dementia Training Requirements(3) Initial Training: Each assisted living residence is responsible for ensuring that all direct-care staff members are trained in dementia diseases and related disabilities.(c) For direct-care staff members already employed prior to January 1, 2024, the initial training must be completed as soon as practical, but no later than 120 days after January 1, 2024, unless an exception, as described in sub-part 7.8(B)(4)(a), applies.(d) For direct-care staff members hired or providing care on or after January 1, 2024, the initial training must be completed as soon as practical, but no later than 120 days after the start of employment or the provision of direct-care services, unless an exception, as described in sub-part 7.8(B)(4)(B), applies. 7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows:(C) The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training, and shall include, but is not limited to, the following topics:(1) Overview of state regulatory oversight applicable to the assisted living residence;(2) Person-centered care;(3) The role of and communication with external service providers;(7) How to safely provide lift assistance, accompaniment, and transport of residents;(10) Understanding the staff or volunteer's role in end of life care including hospice and palliative care. 13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements: (A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either: (1) The resident cannot explain how the injury occurred; or (2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries. (B) The assisted living residence shall document the following: (1)The investigation and identification of any injury identified in (A), above. (2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin: (a) (b) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse, neglect, or exploitation. Such steps may include, but not be limited to: (i) (ii) Staff or volunteer corrective action and/or additional training; or Modification of the assisted living residence's policies, procedures or physical environment.(3) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries.(C) All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request. (1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes. (D) The assisted living residence shall notify the resident's representative of the outcome of the investigation and steps taken.

An involuntary discharge appeal survey, prompted by #CO36029, was completed on 5/29/24. No deficiencies were cited.