ATRIA LONGMONT

A revisit survey was completed on 7/17/26 for all previous deficiencies cited on 5/19/26. The agency is in compliance with all regulations surveyed.

An administrative relicensure survey was completed on 5/27/26. No deficiencies were cited.

A licensure complaint, prompted by CO40231 and CO41541, was completed on 5/19/26. Deficiencies were cited.

Based on interviews and record reviews, the residence failed to complete a comprehensive assessment for a resident ' s change of condition. Findings include:Record reviewThe Residency Agreement, dated 6/15/25, revealed that the residence would reassess the resident's needs during their stay, as needed, and that the resident assessments were part of the deciding factor in determining and monitoring staffing levels and needs for the resident. The residence completed a post admission 30-day assessment for Resident #5 on 9/18/25. At that time, Resident #5's assessment, dated 9/18/25, noted she did not require any status checks. According to the assessment, status checks were required for recent hospitalizations, illness, or medication changes. The frequency of the status checks could be every shift, every two hours, or twice every shift. The next assessment for Resident #5 was not completed until 1/22/26 when Resident #5 moved out of the residence. Hospital records revealed that Resident #5 admitted to the hospital from 12/13/25-12/15/25 for a urinary tract infection (UTI), and then admitted to the hospital again from 12/25/25-12/28/25 for sepsis from a UTI. No new assessments were completed after the two hospitalizations in December 2025, however the resident had two hospitalizations and medication changes (antibiotics) as a result (see the above requirements for status check changes). InterviewsOn 5/18/26 at 3:31 p.m., Staff #2 said an assessment for Resident #5 was not completed because they did not think Resident #5 needed additional care beyond what was already being provided by the residence.

Based on interviews and record reviews, the residence failed to develop a care plan with resident specific personal service needs and preferences, along with the staff tasks necessary to meet those needs. Findings include:Record reviewThe Residency Agreement, dated 6/15/25, revealed that the residence would reassess the resident's needs during their stay, as needed, and that the resident assessments were part of the deciding factor in determining and monitoring staffing levels and needs for the resident. The residence completed a post admission 30-day assessment for Resident #5 on 9/18/25. At that time, Resident #5's assessment, dated 9/18/25, noted she did not require any status checks. According to the assessment, status checks were required for recent hospitalizations, illness, or medication changes. The frequency of the status checks could be every shift, every two hours, or twice every shift. The next assessment for Resident #5 was not completed until 1/22/26 when Resident #5 moved out of the residence. InterviewsOn 5/18/26 at 3:31 p.m., Staff #2 said a new assessment and care plan for Resident #5 were not completed because Staff #2 did not think Resident #5 needed additional care beyond what was already being provided by the residence. Staff #2 said a change in the level of care offered by the residence was not meant to be a solution for a short amount of time. On 5/18/26 at 3:50 p.m., the administrator stated they did not see the need for a new assessment and care plan for Resident #5 based on feedback from Staff #2. Resident #5 was not interviewed as she had moved out of the residence on 1/22/26.

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 9/17/24. 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 licensure complaint, prompted by #CO37449, was completed on 9/17/24. Deficiencies were cited.

Based on record review, observation and interview, the residence failed to maintain resident records that included progress notes that contained pertinent information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affected a resident's physical and functional condition, along with the action taken by staff to address the resident's changed needs affecting three of three sample residents. Findings include 1. References The residences Managing Electronic Resident Notes, dated 1/14/21, read in part, all authorized employees must enter general notes regarding routine updates, communications between family, responsible party and medical provider and notes must be entered within 24 hours of observation of a change in condition or by next business day. 2. Record Review The residence's day to day shift log read as follows;On 9/5/24 Resident #1 found a bed bug. On 9/6/24 Resident #1 temporarily moved to another room. On 9/15/24 Resident #4 had bed bugs and four bites on his arm. On 9/15/24 Resident #5 had bed bugs, took two photos. On 9/16/24 Resident #4 was temporarily moved to another room. September 2024 progress notes were requested for Resident #1, #4 and #5. Their progress notes did not include information about bed bugs or temporary room changes. 3. Interviews On 9/17/24 at 11:03 a.m., the maintenance director stated Resident #4 ' s room was being inspected and treated for bed bugs recently. He stated Resident #1 ' s room was inspected and treated for bed bugs on 9/6/24. Also, he stated he had instructions to move both residents while their rooms were being treated. On 9/17/24 at 11:30 a.m., the administrator stated the residence did not create a progress note for bed bugs as they were not a clinical situation that required documentation. She acknowledged the residence had not created progress notes for out of the ordinary events although she acknowledged temporarily moving to a different room and treating for bed bugs was out of the ordinary. On 9/17/24 at 2:07 p.m., the resident services director (RDS) acknowledged there were reports of bed bug bites on 9/15/24 and again on 9/16/24 on Resident #4. The RDS stated she did not see any bites when she checked on 9/17/24, however there was no way to track due to a lack of progress notes.

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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.

A revisit survey was completed on 9/13/24 for all previous deficiencies cited on 6/18/24. 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 complaint #CO28399 was completed on 6/18/24. Deficiencies were cited.

Based on an interview and record review, the residence failed to ensure that at least one staff member onsite at all times was certified in cardiopulmonary resuscitation (CPR), affecting 12 current residents (#7-#18) who elected to receive CPR in the event it was required. (Cross-reference S0736)Findings include:The residence ' s Emergency Response policy, dated 4/23/18, read in part that if the resident elected to receive CPR in the event it was required, the residence staff initiated any life-saving measures. The residence provided all CPR certifications for all certified staff; however, the residence did not provide CPR certifications for Staff #5-#7. The June 2024 staff schedule read in part that Staff #5-#7 were the only staff who worked on 6/16/24 and 6/17/24 from 10:00 p.m. until 6:30 a.m. Therefore, the residence did not have a CPR-certified staff member onsite on 6/16/24 and 6/17/24 from 10:00 p.m. until 6:30 a.m. On 6/18/24 at 10:38 a.m., the residence services director (RSD) stated that all residence care staff were CPR certified; however, in a later interview at 3:32 p.m., she acknowledged that not all care staff, including Staff #5-#7, had current certifications. She added that no staff member with CPR certification worked the overnight shift on 6/16/24 and 6/17/24 as required. On 6/18/24 at 3:47 p.m., the administrator stated that the residence was required to have one staff member onsite at all times who was certified in CPR. She added that Staff #5-#7 did not have CPR certifications, and they were the only staff members who worked the overnight shifts on 6/16/24 and 6/17/24.

Based on observation and interview, the residence failed to place a list of all staff members who had current certification in first aid and cardiopulmonary resuscitation (CPR) in a visible location, affecting 12 current residents (#7-#18) who elected to receive CPR in the event it was required. (Cross-reference S0734)Findings include:On 6/18/24, during an environmental tour at approximately 7:30 a.m., there was no evidence of a visible list of staff with current first aid and CPR certifications. On 6/18/24 at 3:32 p.m., the resident services director (RSD) stated that the residence had no visible list of CPR-certified staff. She added she was not aware of the requirement. The RSD affirmed that it made sense to have the list readily available for staff. On 6/18/24 at 3:47 p.m., the administrator stated that a list of CPR and first aid-certified staff was not posted and stated she was unaware it was a requirement.

Based on observation, interview, and record review, the residence failed to make available, either directly or indirectly through a resident agreement, a safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, or housekeeping, affecting 16 current residents in the secure environment (SE) and Resident #1. Findings include: 1. Residence AgreementThe residence ' s Residency Agreement, dated 7/7/21, read in part that the residence provided regular housekeeping, carpet cleaning, and oversight. 2. Fireplacea. ObservationsOn 6/18/24, at 10:27 a.m., in the SE, there was a fireplace located in the main living room. A lightweight grate was sitting in front of the fireplace. The grate was easily moved to the side, exposing the fireplace glass which presented a burn risk. On 06/18/24, at 11:01 a.m., in the SE, the temperature of the glass on the fireplace was 158 degrees fahrenheit (F). b. InterviewOn 6/18/24 at 11:05 a.m., the memory care director (MCD) stated that the residence should have secured the grate surrounding the fireplace due to the dangerously high temperature of the glass surrounding the fireplace. On 06/18/24 at 3:31 p.m., the MCD stated that she had concerns for the fireplace to be a potential burn risk. On 6/18/24 at 3:56 p.m., the administrator stated that when the glass of the fireplace was at a temperature of 156 degrees F, it was not safe for the residents in the SE.3. HousekeepingOn 6/18/24 at 11:05 a.m., the carpet in the room of Resident #1 had a trail of blood spot stains that ranged in size between one-half inch to two inches and ran approximately five feet from his bedroom to the bathroom. A residence list of residents who experienced recent falls, dated 4/21/24-6/14/24, read in part that Resident #1 fell on 6/14/24. A progress note, dated 6/16/24, read in part that Resident #1 returned from the hospital and sustained a laceration to his leg. On 6/18/24 at 11:05 a.m., Resident #1 stated that he had had a fall that resulted in an injury that caused him to bleed onto the carpet. He stated he walked from his bedroom [where the resident had fallen] to the bathroom to grab something to stop the bleeding. He stated he arrived back at the residence after returning from the emergency department (ED) and was informed that someone from the maintenance department had cleaned the carpet. Resident #1 stated he verbally asked the maintenance staff to come back and clean it again or have it removed once he learned the carpet was cleaned, but the maintenance staff did not re-attempt to clean it. On 6/18/24 at 1:36 p.m., the maintenance director (MD) stated that he was not made aware that there was blood on Resident #1 ' s carpet until approximately eight hours after the fall occurred and had done the best he could, considering that "[Resident #1] walked around all over the place." The MD stated that the "staff was supposed to inform his department earlier than when they did."On 6/18/24 at 3:51 p.m., the administrator stated she was aware that Resident #1 fell and sustained an injury, which caused blood stains on the resident ' s carpet. She stated she would have to look at the work order to know how she was made aware the carpet was cleaned. She also stated she had not been in the room since Resident #1 returned from the emergency room on 6/14/24. Upon viewing the current condition of the carpet in Resident #1's room, the administrator agreed that the carpet did not look clean and stated she "would want it cleaned immediately if her carpet looked that way."

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 7.9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum:(A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of:(A) A decline from a resident's baseline status;(B) A resident's pattern of refusal;(C) A resident's repetitive request for and use of PRN medication;(D) Any observed or reported unfavorable reactions to medications;(E) The administration of medications used to emergently treat angina; and(F) Medication errors that affect the resident.

A revisit survey was completed on 7/17/23 for all previous deficiencies cited on 7/2/21. The facility is in compliance with all deficiencies were cited.