Balfour at Central Park

A revisit survey was completed on 4/1/26 for all previous deficiencies cited on 11/12/25. 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 #CO39009, was completed on 11/12/25. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure the administrator and qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration records affecting 66 current residents. Findings include:On 11/11/25 at 8:00 a.m., the last two quarterly medication audits were requested. Review of the audits revealed they were being conducted by the pharmacy the residence was.. Based on observation and interview the residence failed to maintain a physically safe and sanitary environment, affecting 66 current residents.Findings include:On 11/11/25, during the on-site environmental tour from approximately 7:00 a.m. to 4:00 p.m., the following was observed:The grand stairwell had a step landing at the bottom of the stairwell, stretching approximately three feet until reaching the hand rail. Also, the top step of the gr.. Based on observation and interview, the residence failed to place in a visible location a list of all staff who havecurrent certification in first aid or cardiopulmonary resuscitation (CPR) so that the information is readily availableto staff at all times, affecting 66 current residents.Findings include:During the onsite visit on 11/11/25, the residence failed to have a list of staff members with current certification infirst aid and CPR in a visible location and .. Based on observation, record review and interview, the residence failed to ensure there was at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization and shall include a skills assessment observed and evaluated by an instructor, affecting 66 current residents who may require obstructed airway techniques. Findings include:On 11/12/.. Based on observation, record review and interview, the residence failed to ensure there was at least one staff member onsite at all times with current certification in first aid from a nationally recognized organization, affecting 66 current residents.Findings include:On 11/12/25 at approximately 10:52 a.m., the residence provided first aid certifications; however,the certifications for five staff members, #5-#9, were not from a nationally recognized organization. 10/29 .. Based on record review and interview, the residence failed to have emergency policies addressing all required elements, affecting 66 current residents. Findings include:The residence' s emergency plan failed to include the following: policies that address a pre-determined means of communicating with residents, families, staff and other providers. The emergency plan also failed to include storage and preservation of medications. Lastly, the plan of pro.. 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 7.14.29 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, ..

A licensure revisit was completed on 8/8/24 for all previous deficiencies cited on 10/8/22. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on record review and interview the residence failed to comply with authorized practitioner orders affecting one sample resident (#21).This deficiency was cited previously during a state licensure survey 10/18/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #21 was admitted to the residence on 3/15/23.A written practitioner' s order, dated 3/21/24, directed the residence to administer acetaminophen 500 mg three times daily. However, the July and August 2024 medication administration records (MARs) for Resident #21 read the residence failed to administer the medication because the medication was out of stock for one dose on 7/6, 7/14, 7/21, 7/28, 8/3, and 8/5/24; for two doses on 7/17, 7/19, and 8/4/24; and for three doses on 7/7, 7/15, 7/16, 7/18, and 8/6/24. This was a total of 21 missed doses.On 8/8/24 at 1:10 p.m., the senior director of health and wellness stated the residence did not have the medication in stock and did not administer it due to communication issues with the external services provider who ordered it.On 8/8/24 at 1:25 p.m., the administrator stated he expected the residence to administer medications as ordered and to have enough stock, or other means to acquire the required medications. The administrator added the reason there was continued deficient practice was because some of the residence' s processes were not done correctly.

A licensure revisit was completed on 8/8/24 for all previous deficiencies cited on 10/18/22. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on record review and interview the residence failed to comply with authorized practitioner orders affecting one sample resident (#21).This deficiency was cited previously during a state licensure survey 10/18/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #21 was admitted to the residence on 3/15/23.A written practitioner' s order, dated 3/21/24, directed the residence to administer acetaminophen 500 mg three times daily. However, the July and August 2024 medication administration records (MARs) for Resident #21 read the residence failed to administer the medication because the medication was out of stock for one dose on 7/6, 7/14, 7/21, 7/28, 8/3, and 8/5/24; for two doses on 7/17, 7/19, and 8/4/24; and for three doses on 7/7, 7/15, 7/16, 7/18, and 8/6/24. This was a total of 21 missed doses.On 8/8/24 at 1:10 p.m., the senior director of health and wellness stated the residence did not have the medication in stock and did not administer it due to communication issues with the external services provider who ordered it.On 8/8/24 at 1:25 p.m., the administrator stated he expected the residence to administer medications as ordered and to have enough stock, or other means to acquire the required medications. The administrator added the reason there was continued deficient practice was because some of the residence' s processes were not done correctly.

A licensure complaint, prompted by #CO30933, was completed on 8/8/24. Deficiencies were cited. Based on observation and interview the residence failed to comply with regulatory standards by not ensuring that each resident' s right to refuse medication was upheld, affecting one sample resident (#14). (Cross-reference S1528)Findings include:Resident #14 was admitted to the residence on 9/30/21 with diagnoses of Alzheimer' s disease, Hypothyroidism, primary pulmonary hypertension, and chronic peripheral venous insufficiency.On 8/8/24 at 8:00 a.m., Staff #17 attempted to administer docusate sodium mixed in juice to Resident #14 and encouraged the resident to drink. The resident refused by saying "no." Staff #17 continued to try to get Resident #14 to drink and held the cup to her lips for more than 10 seconds while Resident #14 audibly moaned in a negative manner. On 8/8/24 at 1:20 p.m., .. Based on observation and interview, the assisted living residence failed to comply with regulatory standards by permitting a qualified medication administration person to perform the task of concealing medication in food or liquid affecting one sample resident (#14). (Cross-reference S1554)Resident #14 was admitted to the residence on 9/30/21 with diagnoses of Alzheimer' s disease, hypothyroidism, primary pulmonary hypertension, and chronic peripheral venous insufficiency.On 8/8/24 at 8:00 a.m., Staff #17 administered acetaminophen and vitamin D3 in applesauce to Resident #14 and stated, "It' s ice cream, try it," to Resident #14 without identifying that the applesauce contained medication. On 8/8/24 at 1:20 p.m., the senior director of health and wellness stated, "masking medication is unacceptable." On .. Based on record review and interview the residence failed to comply with authorized practitioner orders affecting one sample resident (#21).Findings include:Resident #21 was admitted to the residence on 3/15/23.A written practitioner' s order, dated 3/21/24, directed the residence to administer acetaminophen 500 mg three times daily. However, the July and August 2024 medication administration records (MARs) for Resident #21 read the residence failed to administer the medication because the medication was out of stock for one dose on 7/6, 7/14, 7/21, 7/28, 8/3, and 8/5/24; for two doses on 7/17, 7/19, and 8/4/24; and for three doses on 7/7, 7/15, 7/16, 7/18, and 8/6/24. This was a total of 21 missed doses.On 8/8/24 at 1:10 p.m., the senior director of health and wellness stated the residence di.. Based on record review and interview the residence failed to only administer medications ordered by an authorized practitioner, affecting one sample resident (#6).Findings include:Resident #6 was admitted to the residence on 8/27/21.The residence administered medication to Resident #6 in July 2024 without practitioner' s orders as follows:Amlodipine besylate 10 mg once daily 7/1-7/26/24 and 7/30-7/31/24 for a total of 28 dosesAtorvastatin calcium 10 mg once daily 7/1-7/31/24 for a total of 31 dosesCetirizine HCL 10 mg once daily 7/1-7/5/24 and 7/7-7/31/24 for a total of 30 dosesOmeprazole 20 mg once daily 7/2-7/20/24 and 7/25-7/31/24 for a total of 26 dosesPsyllium fiber twice daily 7/1-7/31/24 for a total of 62 dosesVitamin B-12 once daily 7/1-7/31/24 for a total of ..