Limelight Assisted Living - Weaver LLC

A recertification survey, with a complaint #CO40852,was completed on 9/18/2025. Deficiencies were cited. Based on observation and interviews, the facility (residence) failed to ensure the members' (residents' ) right to dignity, affecting three of four sample residents (#1, #2, #4).Findings include:1. ObservationsOn 9/9/25 at approximately 12:40 p.m., Staff #2 was observed wearing headphones and speaking to someone through them while four residents were seated at the dining room table eating lunch. Staff #2 placed meals in front of each resident without speaking or engaging with them and continued his conversation through the headphones. He did not treat the residents with respect and appeared to ignore them.On 9/11/25 at approximately 11:00 a.m., Resident #1 went outside to retrieve the mail. The administrator exited his office, immediately took the mail from Resident #1 ' s hands, and stated that he would handle it. Resident #1 became upset and said, "I have the right to get the mail." The administrator did not respond and walked away.2. InterviewsOn 9/9/25 at 12:55 p.m., Resident #2 stated that Staff .. Based on record review, observations and interviews, the facility (residence) failed to provide members (residents) with social and recreational engagement opportunities both within and outside the setting, affecting 12 current residents.Findings include:1. Record ReviewA September 2025 activity schedule read on 9/9/25 the daily activities were: This day in history and a puzzle.2. ObservationsOn 9/9/25 at approximately 12:45 p.m. to 4:30 p.m., staff did not offer residents opportunities to engage in scheduled activities. Residents were observed napping or watching television in their rooms, outside smoking cigarettes or sitting in the living room for several minutes before returning to their rooms. On 9/9/25 at 1:17 p.m., a September 2025 calendar was hung on a wall in the dining area, displaying activities for each day of the month. On 9/10/25 at 10:08 a.m., Staff #1 gathered residents to a meditation session in the living room. Resident #4 responded to Staff #1 and said "huh, an activity?"3. InterviewsOn 9/9/25 at 12:55 p.m., .. Based on records review, observations and interviews, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting four sample (#1-#4).Specifically, Resident #1 was prescribed hydrocodone on a pro re nata (PRN) basis, every six hours as needed. From8/29 to 9/11/25, Resident #1 consistently reported severe pain and requested hydrocodone daily. However, theresidence did not have the medication in stock and was therefore unable to administer it. This failure placed the residence in immediate jeopardy due to the failure to comply with practitioner orders for Resident #1, resulting in him experiencing severe pain. On 9/11/25, the department directed the residence to submit written evidence confirming that the risk had been removed.Findings include:1. Residence PolicyAn undated Medication Administration Policy read in part that the administrator was responsible for ensuring adequate professional oversigh..

A relicensure survey, with a complaint #CO40853,was completed on 9/18/2025. Deficiencies were cited.A change of ownership occurred on 8/19/25. Based on observation and interviews the residence failed to ensure residents were treated with dignity and respect, affecting three of four sample residents (#1, #2, #4).Findings include:1. ObservationsOn 9/9/25 at approximately 12:40 p.m., Staff #2 was observed wearing headphones and speaking to someone through them while four residents were seated at the dining room table eating lunch. Staff #2 placed meals in front of each resident without speaking or engaging with them and continued his conversation through the headphones. He did not treat the residents with resp.. Based on record review, observation and interview, the residence failed to comply with licensure requirements by caring for more residents than the number of beds for which it was currently licensed, affecting 13 current residents.Findings include:On 9/18/25, an undated resident roster revealed that the residence was providing services to 13 residents.On 9/18/25 at approximately 11:45 a.m., 13 residents were observed residing in the residence during an environmental tour.On 9/18/25 at 3:52 p.m., the administrator acknowledged that the residence was licensed for.. Based on record review, observation and interview, the residence failed to make available a physically safe and sanitary environment, affecting 13 current residents.Findings include:1. Record ReviewAn undated list of smokers revealed that there were six residents who smoke cigarettes. One of those residents used a walker to ambulate.2. ObservationsAn environmental tour of the residence, conducted on 9/9/25 at 12:35 p.m., revealed a mold-like substance along the baseboards in residents ' bathrooms. The common bathrooms had missing tiles in the show.. Based on record review, observation and interview, the residence failed to provide residents with regular opportunities to participate in structured engagement activities, affecting 12 current residents. Findings include:1. Record ReviewA September 2025 activity schedule read on 9/9/25 the daily activities were: This day in history and a puzzle.2. ObservationsOn 9/9/25 at approximately 12:45 p.m. to 4:30 p.m., staff did not offer residents opportunities to engage in scheduled activities. Residents were observed napping or watching television in their rooms, outside sm.. Based on record review, observation, and interview, the residence failed to comply with authorized practitioner orders, affecting one sample resident (#1).Specifically, Resident #1 was prescribed hydrocodone on a pro re nata (PRN) basis, every six hours as needed. From8/29 to 9/11/25, Resident #1 consistently reported severe pain and requested hydrocodone daily. However, theresidence did not have the medication in stock and was therefore unable to administer it. This failure placed the residence in immediate jeopardy due to the failure to comply with practition.. 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 (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.(C) Each qualified medication administr..

A revisit survey was completed on 2/26/25 for all previous deficiencies cited on 9/4/24. 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 revisit survey was completed on 9/4/24 for all previous deficiencies cited on 2/10/23. A deficiency was cited. Based on observation, interview and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations., affecting 10 current members (residents). This deficiency was cited previously during a state certification survey on 2/10/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. Chapter VII regulations, part 14.21, requires 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. a. Resident #13 was admitted to the residence on 1/19/19 with diagnoses including depression, anxiety, and bipolar. Magnesium A written practitioner order dated 1/18/24 directed the residence to administer half a tablet of magnesium once daily for anxiety. However, the September and August 2024 electronic administration records (eMAR) for Resident #13 read that the medication was not available on 8/1/24-8/4/24, 8/8/24-8/11/24, 8/15/24-8/18/24, 8/22/24-8/25/24, and 8/29/24-9/1/24 for 20 missed doses. Oxycodone A written practitioner order, dated 4/23/24, directed the residence to administer 10 mg of oxycodone, one tablet, three times daily. However, the September and August 2024 eMAR for Resident #13 read the medication was not available on 8/6/24 and 8/27/24-8/29/24 for four missed doses. b. Interviews On 9/4/24 at 12:45 p.m., Staff #4 said when residents were not administered medications it was because the resident was waiting on practitioner orders. However, Staff #4 also stated the pharmacy automatically sent the medications to the residence on a cycle and medications should never be out of stock. On 9/4/24 at approximately 1:30 p.m., the administrator said the pharmacy sent medications on a cycl..

A revisit survey was completed on 9/4/24 for all previous deficiencies cited on 2/10/23. Seven deficiencies were cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on observation, record review and interview, the residence failed to ensure medications were in a locked cart when unattended by qualified medication administration persons (QMAPs), affecting 10 current residents. This deficiency was cited previously during a state licensure survey 2/10/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirem.. Based on observation, record review and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets, affecting seven of seven residents who smoked. This deficiency was cited previously during a state licensure survey 2/10/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: The administrator pr.. Based on observation, record review and interview, the residence failed to ensure there was a readily available roster of current residents, their room assignments and emergency contact information, along with a diagram showing room locations, affecting 10 current residents.This deficiency was cited previously during a state licensure survey 2/10/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintain.. 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 cardiopulmonary resuscitation (CPR) so that the information was readily available to staff at all times, affecting 10 current residents.This deficiency was cited previously during a state licensure survey 2/10/23. Although the residence corrected the deficiency, based on the findings below, the residen.. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting two of three sample residents (#11, #13). This deficiency was cited previously during a state licensure survey 2/10/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirem.. Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire, gas explosion, power outages, tornado, flooding and threatened or actual acts of violence, affecting 10 current residents.This deficiency was cited previously during a state licensure survey 2/10/23. Although the residence corrected the deficie.. Based on record review and interview, the residence failed to ensure the process for raising and addressing grievances and complaints was placed in a visible on-site location and that the grievance policy contained required contact information, affecting 10 current residents.This deficiency was cited previously during a state licensure survey 2/10/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maint.. 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