Balfour at Littleton

A revisit survey was completed on 9/15/25 for all previous deficiencies cited on 4/15/25. 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 #CO39807 was completed on 4/15/25. Deficiencies were cited.A change of ownership occurred on 10/1/24 Based on observation and interview, the residence failed to ensure the residence grounds were maintained to protect residents from slopes and hazards, affecting 70 current residents. Findings include:On 4/15/25 at approximately 8:00 a.m., 8:30 a.m., and 1:15 p.m., environmental tours revealed the residence had a sidewalk that spanned from the north-facing front of the residence to the west side of the building. The sidewalk had several areas that ran.. Based on observation and interview, the residence failed to place in a visible location a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR) so that the information is readily available to staff at all times, affecting 70 current residents.Findings include:During the onsite visit on 4/14/25, the residence failed to have a list of staff members with current certification in first aid and CPR in a visible location and readily a.. Based on observation and interviews, the residence failed to have a clean refuse storage area that had tight fitting lids and kept clean, affecting 70 current residents. Findings include: On 4/15/25, at 8:00 a.m., an observation of a refuse area surrounded by a wooden structure, with a door left open, revealed multiple recycling and refuse bins. One of the refuse bins contained five to six large bags of waste that could not fit in the bin with a tight-fitting lid. A used round .. Based on observation, interview and record review, the residence failed to ensure the care plan for each resident in a secure environment included a description of how the resident will have continuous independent access to his or her individual room along with the ALR' s plan to protect the resident from unwanted visitors, affecting four of four sample residents (#8 and #15-#17) who resided in the secure environment.Findings include:Resident #8 was admitted to the .. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of five sample residents (#15, #17, and #20).Findings include:1. Resident #17 was admitted to the residence on 10/26/23.A written practitioner' s orders, dated 3/13/25, directed the residence to administer four grams of cholestyramine daily for 30 days.According to the March 2025 and April 2025 m.. Based on record review and interview, the residence failed to provide pest control measures to ensure the residence doors, door screens, and window screens fit with sufficient tightness at their perimeters to exclude pests, affecting 46 current residents.Findings Include:On 4/15/25 at approximately 7:00 a.m., upon arrival, a window screen was observed leaned up against the building. On 4/15/ 2025, at approximately 8:00 a.m., a window on the rear east side .. 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 7.14.7 The assisted living residence shall ensure that each resident receives proper administration and/or monitoring of medications. 14.27 No stock medications shall be stored or administered ..

A complaint revisit was completed on 4/15/25 for all previous deficiencies cited on 3/1/23. 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 observation, interview and record review, the residence failed to ensure the care plan for each resident in a secure environment included a description of how the resident will have continuous independent access to his or her individual room along with the ALR' s plan to protect the resident from unwanted visitors, affecting four of four sample residents (#8 and #15-#17) who resided in the secure environment.This deficiency was cited previously during a state licensure complaint on 3/1/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #8 was admitted to the residence on 5/26/22 with diagnoses including dementia. A care plan, dated 4/12/25, did not include a description of how the resident would have continuous independent access to her individual room.On 4/15/25 at approximately 2:30 p.m., the administrator said most residents in the secured environment do not have keys. She said she was unsure who had keys to their rooms. She said the residents who had keys had that documented in the care plan. She said care plans did not document how residents would have continuous access to their rooms while keeping unwanted guests out. She said she thought this was fixed by documenting the residents who had keys. She said she was unaware she needed to include a description of how the resident will have continuous independent access to their room, along with the residence' s plan to protect the resident from unwanted visitors in the resident' s care plan. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with authorized practitioners' orders associated with medication administration for Residents #15-#17.

A licensure complaint, prompted by #CO30879 and #CO31021 was completed on 3/1/23. Deficiencies were cited. Based on observation and interview, the residence failed to ensure weekly menus were readily available for residents and public viewing, affecting 17 sample residents who resided in the secure environment. Findings include:On 3/1/23 from approximately 7:15 a.m. to 12:00 p.m., there was no weekly menu readily available for residents and public viewing in the secure environment. There was no evidence of a menu booklet accessible to residents.On 3/1/23 at 7:15 a.m., Staff #3 stated she was not sure where to locate the weekly menu in the secure environment.On 3/1/23 at 11:40 a.m., Staff #2 stated the staff got the menu with four options printed out the night before and added staff would ask the residents what they wanted by showing them the menu. Staff #2 stated the memory care director (MC.. Based on observation, interview and record review, the residence failed to ensure the care plan for each resident in a secure environment included a description of how the resident will have continuous independent access to his or her individual room, affecting 11 of 17 sample residents (#1-#5, #9-#14) who resided in the secure environment.Findings include:1. Resident #1 was admitted to the residence on 3/4/22 with diagnoses including dementia. On 3/1/23 at approximately 11:10 a.m., the resident was in the common area and her bedroom door was locked.A care plan, dated 10/13/22, did not include a description of how the resident would have continuous independent access to her individual room.On 3/1/23 at 11:32 a.m., the legal representative for Resident #1 confirmed the resident was unable.. Based on observation, interview and record review, the residence failed to reassess residents in the secure environment whenever the resident' s condition changed from baseline status, affecting two of two sample residents (#1, #2) who had a condition change from baseline status.1. Residence PolicyThe residence Change in Resident Policy, dated 5/9/22, read in part, "Community staff have the responsibility to provide care to each resident and summon medical attention when the resident has a change in status. Examples of change would include, but not limited to: decreased mobility/range of motion, weakness, decreased coordination, hallucinations or unusual behavior, change in level of consciousness, decrease in cognitive decline, pain or discomfort. If there is an actual change in status or abil.. 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 one sample resident (#2) with a history of falls. Specifically, Resident #2 sustained a fall without injury on 12/11/22, 2/25/23. 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 a series of additional falls on 2/18/22, 2/26/23 that resulted in skin tear on the right hand, 0.5 cm abrasion on the left lower abdomen; and 1.5 cm abrasions to the right elbow respectively. ..