Limelight - Golden Orchard Assisted Living Mc

A licensure complaint, prompted by #CO36041 and #CO36108, was completed on 5/21/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affects a resident' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident' s changing needs... Based on interview and record review, the residence failed to ensure staff assigned to a secure environment received training and education on the mobility status of all residents so that staff are prepared to successfully evacuate all residents in the event of an emergency for one staff (#2), affecting 11 current residents.Findings include:On 5/21/24.. Based on interview and record review, the residence failed to ensure that each staff member received initial orientation prior to providing any care or services to a resident, affecting eleven current residents.Findings include:On 5/21/24 at 2:41 p.m., review of personnel files for Staff #1-#3 revealed Staff #2 was hired on 5/4/24 and had not co.. Based on interview and record review, the residence failed to have a readily available roster of current residents that contained emergency contact information, along with a facility diagram showing room locations, affecting eleven current residents.Findings include:On 5/21/24 at 9:55 a.m., the administrator designee was asked to provide a resid.. Based on observation, interview and record review, the residence failed to ensure all interior areas including basements were free from accumulations of extraneous materials such as refuse and unused or discarded furniture, affecting 11 current residents.Findings include:On 5/21/24 at approximately 8:15 a.m., the back portion of the base.. Based on observation, interview and record review, the residence failed to ensure residents had the right to be free from neglect, affecting one sample resident (#1). (Cross-reference S1160, S2230, S3060)Findings include:1. Record ReviewResident #1 was admitted to the residence on 8/30/19 with diagnoses including dementia.Progress notes docu.. Based on observation, record review, and interview, the residence failed to have heat and ventilation sufficient to meet the needs of a resident, affecting one sample resident (#2).Findings include:On 5/21/24 at approximately 9:45 a.m., the temperature in Resident #2' s room measured between 77 and 79 degrees Fahrenheit (F). On 5/21/24 at ap.. Based on record review and interview, the residence failed to be responsible for the coordination of resident care services with known external service providers (ESPs), affecting one sample resident (#1). (Cross-reference S1324)Findings include:Resident #1 was admitted to the residence on 8/30/19 with diagnoses including dementia.A w.. Based on record review and interview, the residence failed to have a care plan that included a description of the resident' s known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident, affecting one sample resident (#1).Findings include:Resident #1 was admitted to the residence on 8/30.. 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 7.10.6 Each assisted living residence' s emergency policies shall address, at a minimum, all of t..

A relicensure survey was completed on 5/18/23. Deficiencies were cited. Based on interviews and record review, the residence failed to hold regular family council meetings at least quarterly, affecting nine current residents: Findings include:On 5/18/23 at 7:45 a.m., the administrator was requested to provide the residence' s family council meeting minutes; however, she was unable to provide the documentation. On 5/18/23 at 8:15 a.m., the administrator stated the residence did not hold quarterly family council meetings, as it was difficult to get all of the family members together at once. She stated if there were any issues or.. Based on observation and interview the residence failed to ensure the handrails were maintained and in good repair, affecting nine current residents. Findings include: During an environmental tour of the secured outdoor environment on 5/18/23 at 7:50 a.m., revealed the handrail posts that surrounded the backyard patio and the ramp were rusted at the bottom of the posts. Five of the handrail posts had been completely rusted through which left large holes in the posts. The gate at the top of the ramp had a rusted piece at the bottom of the gate which prevented it from closing... Based on observation, 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 along with the full contact information for the Colorado Department of Health Care Policy and Financing, affecting nine current residents.Findings include:1. Residence policyThe residence' s undated Resident Grievance Policy did not include the full contact information for the Colorado Department of Health Care Policy and Financing.2. ObservationOn 5/18/23 at 7:30 a.m., a tour of the resid.. Based on observation, record review and interview, the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting nine current residents in the secure environment.Findings include: During an environmental tour on 5/18/23 between 7:45 a.m. and 8:00 a.m., the following was found: In the kitchen was a sliding glass door that led to the secure outdoor area. The sliding glass door had a padlock at the top of door, which prevented independent access to the sec.. Based on record review and interview, the residence failed to ensure each personnel file included the required information, affecting two of two sample staff for whom there was a personnel file (#1, #2)(Cross-Reference Q0610)Review of the personnel files for Staff #1 and #2 revealed the following was not included in their files: date of hire and date duties commenced, evidence of CBI results, nor the results of CAPS background checks. On 5/18/23 at 2:15 p.m., the administrator stated she was not aware the CBI results or CAPs checks for Staff #1 and #2 were not in .. Based on record review and interview, the residence failed to ensure that a criminal history record check conducted by the Colorado Bureau of Investigation (CBI) had been conducted prior to hire, for two of two sample staff (#1, #2), affecting nine current residents. (Cross-Reference Q0664)1. Reference Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following items:(E) Results of background checks and follow up, as applicable.2. ObservationOn 5/18/23 between 7:30 a.m. an..