Balfour at Lavender Farms

A licensure complaint, prompted by #CO41554, was completed on 2/9/26. A deficiency was cited. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of two sample residents (#2) and one former resident (#3).Specifically, the residence failed to comply with authorized practitioner orders to administer warfarin sodium, an anticoagulant. The residence was directed to administer 3 mg of warfarin on weekdays to Former Resident #3 (FR#3); however, the January 2026 medication administration record (MAR) revealed the residence failed to administer the medication on 1/7/26. Additionally, the January 2026 MAR revealed FR#3 was administered 7 mg on 1/8 and 1/9/26, instead of the 3 mg that was ordered. On 1/13/26, FR#3 was hospitalized due to a sudden onset of symptoms, which included shortness of breath, radiating chest pain to both shoulders, weakness, low blood pressure, and an inability to smile or answer questions as normal. On 1/13/26, FR #3 was diagnosed with acute hemorrhagic shock, related to complications of anticoagulation therapy. Ultimately, on 1/18/26, FR #3 passed away, and the coroner' s report revealed the former resident' s cause of death to be from warfarin intoxication. Findings Include:1. Reference and Residence Policya. The National Blood Clot Alliance (NBCA) defines the International Normalized Ratio (INR) as the "blood test that measures the time it takes for blood to form a clot. This is called a prothrombin time test, or protime (PT). The PT is reported as the International Normalized Ratio (INR). The INR is a calculation based on PT test results and is used to monitor individuals treated with the anticoagulant warfarin. INR tests are used instead of the PT because the INR is corrected for the strength of your blood-clotting tissue. INR is also used to standardize the method used across all labs to lead to the most accurate results. If a person ' s INR is too low, blood clots may not be prevented. If a person ' s INR is too high, they may experience uncontrolled or dangerous bleeding."b. The residence' s "Medication Pass" policy dated 12/..

A relicensure survey was completed on 7/8/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure resident' s medication administration record(MAR) contained accurate information, affecting one of five residents (#4).Findings include:Resident #4 was admitted to the residence on 11/26/22, with diagnoses including Type 2 diabetes. A written practitioner' s order, dated 6/17/25, instructed the residence to give 36 units of insulin from an insulinpen daily to Resident #4. The July 2025 medication administration record (MAR) read Resident #4 received an insulin injection daily thatwas administered by a family member or a home health nurse daily. However, the July 2025 MAR was blank from7/1 to 7/8/25. On 7/8/25 at 3:18 p.m., the resident care director (RCD) said Resident #4 received daily insulin injections from an external agency. The.. Based on interview and record review, the residence failed to reflect detailed personal service needs and the stafftasks necessary to meet those needs, identify all external service providers along with the care coordinationarrangements in the care plan, affecting three (#1, #2 and #5) of five sample residents. Findings include:1. Record reviewResident #5 was admitted to the residence on 11/26/22, with diagnoses including Type 2 diabetes. A care plan for Resident #4, dated, 6/23/25, read Resident #4 was receiving home health for insulin, physicaltherapy and occupational therapy. The July 2025 medication administration record (MAR) read Resident #4 received an insulin injection daily thatwas administered by a family member or a home health nurse. An external phy.. Based on record review and interview, the residence failed to request, prior to hire, a correct name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for one sample staff (#2), affecting 50 residents.. Findings include:On 7/8/25, starting at 8:06 a.m., and ending at 9:42 a.m., Staff #2 was observed providing medication management for three unknown residents.A personal record for Staff #2 read that the staff member had a hire date of 3/26/25. A background screening report failed to include the results verified through the CBI. The June schedule read in part that Staff #2 worked at the residence on 6/1 - 6/5, 6/8 - 6/12, 6/15 - 6/19, 6/22 - 6/26, and 6/29 - 6/30/25 providing care and services to residents.The July schedule read in part that Staff #2 worked at the re.. Based on record review and interviews, the residence failed to have a readily available roster of current residents, their room assignments, and emergency contact information, along with a facility diagram showing room locations, affecting 50 current residents.Findings include:On 7/8/25 at approximately 7:50 a.m., a resident roster provided by Staff #4 did not contain a facility diagram showing room locations.On 7/8/25 at approximately 8:23 a.m., the residence provided a second roster which did not include emergency contact information or a residence diagram showing room locations.On 7/8/25 at 8:51 a.m., the administrator stated that staff would need to print the resident' s roster with all the required information in the event of an emergency.On 7/8/25 at 5:02 p.m., the adminis..

A revisit survey was completed on 08/08/2023 for all previous deficiencies cited on 01/25/2023. The facility is in compliance with all deficiencies 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 revisit was completed on 1/25/23 for all previous deficiencies cited on 3/1/22. A deficiency was cited. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting two of four sample residents (#2, #47). This deficiency was cited previously during a state licensure survey 3/1/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. Resident #47 was admitted to the residence on 11/11/22 with diagnoses including transient ischemic attack and cerebral infarction. A written practitioner' s order for Resident #47, dated 12/20/22, directed the residence to administer Aspirin 81 mg once daily. The residence' s January 2023 medication administration record (MAR) for Resident #47 read she was not administered Aspirin 81 mg on 1/2-1/7/23, 1/10-1/11/23, 1/14-1/17/23, and 1/21-1/25/23. There were a total of 17 missed doses. On 1/25/23 at 2:16 p.m., the health and wellness director (HWD) stated Resident #47' s practitioner had not sent new orders for the Aspirin 81 mg but stated an order had been sent to the pharmacy. She added the residence had notified the family but they had not brought in the Aspirin and the residence did not obtain Aspirin for Resident #47. 2. Resident #2 was admitted to the residence on 11/10/21 with a diagnosis of dementia. A written practitioner' s order for Resident #2, dated 8/17/22, directed the residence to administer donepezil 10 mg once daily at bedtime. The residence' s January 2023 MAR for Resident #2 read she was not administered donepezil 10 mg on 1/2-1/4/23 and 1/6/23. There were a total of 5 missed doses. On 1/25/23 at 2:16 p.m., the HWD stated the pharmacy informed her there was no order on record for Resident #2' s donepezil because Resident #2' s practitioner had not requested the medication from the pharmacy. She added, Resident #2' s medications should have arrived at the residence routinely. 3. Interviews On 1/25/23 at 1:50 p.m., the administrator stated the HWD was responsible for medication orders. She ..

A licensure revisit was completed on 1/25/23 for all previous deficiencies cited on 4/5/22. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each staff member completed initial orientation prior to providing care or services to a resident, specific to advance directives for three of five sample staff (#2, #29, #30), affecting 54 current residents.This deficiency was cited previously during a state licensure survey 4/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. Residence AgreementThe residence' s Resident Agreement Addendum, revised February 2022, read in part: "CPR Administration: It is (the residence' s) policy to initiate cardiopulmonary resuscitation ("CPR") and call 911, unless Resident has a valid Do Not Resuscitate Order, a v.. Based on observation, record review and interview, the residence failed to ensure the grounds were maintained to protect residents from hazards, affecting 54 current residents. This deficiency was cited previously during a state licensure survey 4/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. ObservationOn 1/25/23 at 8:54 a.m., an exterior environmental tour was conducted at the residence. The environmental tour revealed sidewalks in the courtyard of the residence and around either side of the residence, including sidewalks outside of doors used to exit the residence, had not been cleared of snow and ice. The snow and ice created a hazard and a risk of injury for .. Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid and/or cardiopulmonary resuscitation (CPR), so that the information was readily available to staff at all times, affecting 54 current residents. This deficiency was cited previously during a state licensure survey 4/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. ObservationOn 1/23/25 at 8:02 a.m., a cardiopulmonary resuscitation (CPR)/first aid certified staff list was posted in the nurses station on the first floor of the residence.2. Record ReviewThe residence' s CPR/first aid certification cards read Staff #1, #13, #30-.. 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 7.7.11 Personnel files for current employees and volunteers shall be readily available onsite for Department review.