Limelight - Golden Orchard Assisted Living AL

A revisit survey was completed on 11/4/25 for all previous deficiencies cited on 11/26/24. 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 #CO40123, was completed on 6/3/25. A deficiency was cited. Based on record review observation, and interview the residence failed to complete a written authorization that specifies the terms and duration of the financial management services, maintain any funds over the amount of five hundred dollars in an interest bearing account, have a surety bond, maintain a continuous, dated record of all financial transactions, and failed to provide receipts for each transaction and a quarterly report identifying the account balance with a description of each and every transaction, affecting one of one sample resident (#3).Findings include:1. Record ReviewResident #3 was admitted to the residence on 9/28/24 with a diagnosis of dementia in other disease classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A practitioner' s order dated 12/9/24 read, Resident #3 had significant progression of cognitive decline. Related to this cognitive decline, it was the practitioner' s professional opinion that Resident #3 was unable to make sound decisions related to personal care, finances, driving, or legal matters. During an on-site visit on June 3, 2025, from 10:00 a.m. to 4:30 p.m., a policy regarding the management of funds or property was requested, however, it was not provided. Additionally, the administrator was unable to provide written and signed authorization specifying the terms and duration of the financial management services to be performed by the residence, a surety bond, a continuous dated record of all financial transactions, receipts each time funds were disbursed, and written personal checks.On 6/3/25 at 2:14 p.m., the administrator provided a notepad with handwritten supplies, quantity of the supplies, and price of the supplies purchased with the total amount spent; however, the notes did not have the resident' s name attached to the note. The administrator was unable to provide receipts for the supplies purchased. 2. Interview On 6/3/25 at 11:19 a.m., the business development and activities director stated the ..

A relicensure survey with complaint #CO36461 was completed on 11/26/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that each personnel file included hire dates, written documentation regarding orientation and training, results of background checks, and documentation of initial dementia training for three of four sample staff (#1, #3 and #4), affecting seven current residents. (Cross-reference .. Based on interview and record review, the residence failed to ensure that each qualified medication administration person documented accurate information in the medication administration record (MAR), including any medication omissions; the residence additionally failed to ensure that, as part of the MAR, the residence maintained a legible lis.. Based on interview and record review, 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 two of three sample residents (#2, #3) and one former resident (#4).Findings include:.. Based on interview and record review, the residence failed to notify a resident' s representative when a resident experienced a change in baseline status, affecting one of three sample residents (#2).Findings include:1. Record ReviewResident #2 was admitted to the residence on 11/12/20.A progress note, dated 11/20/24, read the resident' s l.. Based on observation and interview, the residence failed to appoint a qualified designee to satisfactorily fulfill the administrator' s duties and ensure the name and contact information of the qualified designee were readily available to residents, residence staff, and the public while the administrator was unavailable, affecting seven current residents... Based on observation and interview, the residence failed to ensure all refrigerated medications were clearly labeled with the resident' s name and prescribing information, affecting two of three residents whose medications were reviewed (#1, #2).Findings include: 1. Residence PolicyThe residence' s medication policy, dated June 2022, read in p.. Based on record review and interview, the residence failed to develop and implement a visitation policy which described any restriction or limitation necessary to ensure the health and safety of residents, staff and visitors, affecting seven current residents.Findings include:On 11/26/24 at 8:35 a.m., the residence' s visitation policy was req.. Based on record review and interview, the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring one of four sample staff (#1) who provided direct care to at-risk residents, affecting seven current residents. (Cross-reference S664)Findings include:Staff #1 was hired on an unknow.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting seven current residents.Findings include:On 11/26/24 at 8:35 a.m., the residence' s involuntary discharge grievance policy was requested but not provided.On 11/26/24 at 12:58 p... Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting seven current residents. (Cross-reference S542)Findings include:On 11/26/24 at 8:35 a.m., the following was requested but not provided upon request:For Former Resident #4: March 2024 medic.. 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 7.7.13 If the employee or volunteer is a qualified medication administration person, the follo..