Limelight - Retreat at Highlands

A certification complaint, prompted by #CO39254, #CO39287, #CO39342, #CO39396, #CO40775, #CO41024, #CO41109 #CO41230, and #CO41332, was completed on 1/29/26. Deficiencies were cited. Based on observation, record review, and interviews, the facility (residence) failed to ensure members (residents had access to food and beverage at all times, affecting 48 current members (residents). Findings include:1. ReferenceThe residence ' s undated residency agreement read in part, the residence will provide three balanced meals a day, plus access to alternatives and snacks throughout the day. 2. ObservationDuring an on-site visit from 1/28/26 at 7:30 a.m. to 1/29/26 at 2:00 p.m., no nutritional snacks were observed to be available to residents. Also, there was no alternative menu available to residents. 3. InterviewsOn 1/28/26 at 9:40 a.m., Resident #4 stated the residence provides three meals; however, they did not provide snacks or drinks throughout the day.On 1/28/26 at approximately 10:30 a.m., Resident #8 stated she had been losing weight due to not eating the provided meals because she was a vegetarian, and the residence did not provide any meals that were strictly vegetarian. She stated that she ate peanut butter and jelly sandwiches often; however, had become uninterested in them because of how often she ate them. On 1/29/26 at approximately 11:25 a.m., Staff #2 stated he typically made sandwiches daily and placed them in the dining hall fridge accessible to residents. Staff #2 stated there was no alternative menu available .. Based on record review, observations, and interviews, the facility (residence) failed to provide social and recreational engagement opportunities both within and outside the setting, have access to food at all times. Choose when and what to eat, and have input in menu planning, affecting 48 current residents.Findings include:1. Residence Agreement The residence ' s undated residency agreement read in part, the residence will provide a wide variety of activities, including community outings. 2. Record ReviewA review of the January activities schedule revealed that no outside community activities were scheduled. On 1/28/26, the activities inside the residence listed, Guess the Sound and Puzzle Partners; however, neither activity was observed. On 1/29/26, the schedule listed Gentle Mind Reset for the morning, and no activity was scheduled for the afternoon.3. ObservationsOn 1/28/26, from approximately 8:00 a.m. to 4:30 p.m., staff did not conduct any activities as scheduled. Residents were observed sitting in the kitchen area watching television or wandering, with no activities or community activities offered.4. InterviewsOn 1/28/26 at approximately 10:14 a.m., Resident #10 stated that the residence had an activity schedule, but staff did not follow it as written. Resident #10 reported that when activities were offered, staff provided the same activities daily and did ..

A licensure complaint, prompted by #CO39253, #CO39286, #CO39343, #CO39395, #CO40776, #CO41023, #CO41110, #CO41231, and #CO41333, was completed on 1/29/26. Deficiencies were cited. Based on observation, record review, and interviews, the residence failed to provide nourishing meal substitutes and between-meal snacks, affecting 48 current residents. Findings include:1. ReferenceThe residence ' s undated residency agreement read in part, the residence will provide three balanced meals a day, plus access to alternatives and snacks throughout the day. 2. ObservationDuring an on-site visit from 1/28/26 at 7:30 a.m. to 1/29/26 at 2:00 p.m., no nutritional snacks were observed to be available to residents. Also, there was no alternative menu available to residents. 3. InterviewsOn 1/28/26 at 9:40 a.m., Resident #4 stated the residence provides three meals; howe.. Based on observations and interviews, the residence failed to have sufficient ventilation to meet the needs of the residents, affecting three of three (#1, #5, #10) residents whose environment was reviewed.Findings include:1. ObservationsOn 1/28/26 at approximately 9:30 a.m., during an environmental tour of Resident #5 and #10 ' s room, the room was very congested and had a foul odor. The main window in the room did not open to allow for air circulation. On 1/28/26 at approximately 10:45 a.m., during an environmental tour, it was observed that Resident #1 ' s shared double-occupancy room had only one window, which was located on the roommate ' s side of the room. Resi.. Based on record review and interview, the residence failed to ensure residents were encouraged to participate in planning menus and make reasonable efforts to accommodate resident suggestions, affecting 48 current residents. Findings include:1. PolicyThe residences' October 2017 Food and Nutritional Services policy read in part, the residence will ensure reasonable efforts will be made to accommodate resident choices and preferences. Input from the residents is considered in menu planning. 2. InterviewsOn 1/28/26 at approximately 8:30 a.m., Resident #1 stated the residence provides the residents with inedible foods and does not allow residents to participate in the planning of th.. Based on record review, observation, and interview, the residence failed to provide a safe and sanitary environment, either directly or indirectly through a resident agreement, affecting 48 current residents. Findings include Residence agreementThe residence ' s undated residency agreement read in part, the residence will provide regular housekeeping services. Observation On 1/28/26 from 7:30 a.m to 1/29/26 at approximately 1:00 p.m., during an environment tour of the residence, the following was observed:Upon entering the residence, a strong odor of cleaning chemicals was present throughout the hallways of the residence, later found to be floor cleaning supplies. T.. Based on record review, observations, and interviews, the residence failed to provide community-centered activities, affecting 48 current residents.Findings include:1. Residence Agreement The residence ' s undated residency agreement read in part, the residence will provide a wide variety of activities, including community outings. 2. Record ReviewA review of the January activities schedule revealed that no outside community activities were scheduled. On 1/28/26, the activities inside the residence listed, Guess the Sound and Puzzle Partners; however, neither activity was observed. On 1/29/26, the schedule listed Gentle Mind Reset for the morning, and no activity was scheduled for the ..

An involuntary discharge appeal survey, prompted by #CO39688, was completed on 5/19/25. A deficiency was cited Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy affecting 48 current residents.Findings include:1. Record ReviewOn 5/6/25, at approximately 3:41 p.m., the involuntary discharge policy and residential agreement were requested by email.On 5/12/25, at approximately 4:28 p.m., a copy of the grievance policy and signed residential agreement were received by email.On 5/15/25, at approximately 9:09 a.m., the involuntary discharge policy was received by email. The involuntary discharge policy was reviewed, and the facility failed to follow the following elements:(D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or(2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence.(a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness' s name and contact information, and shall keep that information as part of the grievance documentation.(E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an ap..

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 1/29/25. 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 life safety code survey, prompted by #CO39145, was completed on 2/27/2025. Two deficiencies were cited. The facility is a one-story Type V (000) structure with a partial basement. It is licensed for forty-six (46) residents and only utilizes the partial basement for storage and laundry services. The facility has a National Fire Protection Association (NFPA) 13-R automatic fire suppression system. This survey, conducted on February 27, 2025, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities. Based on observation, interview, and record review the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining means of egress. The facility failures had the potential to affect all occupants of the building.Findings include:Cross-reference to A0001 for observation and interviews documenting the facility failure to keep egress paths in resident accessible hallways and staff accessible hallways free from storage of disused furniture, construction supplies, and musical instruments. These failures presented a risk to resident and other occupant life safety due to reduced pathway availability in the event of a building evacuation. Based on observations and interviews, it was determined that the residence did not maintain means of egress and used storage areas as rooms in accordance with NFPA 101, 2012 Edition. Specifically, the egress throughout the residence was obstructed by disused items affecting all egress pathways. The findings include:Regulatory Reference:33.3.2.3.4 The width of corridors serving an occupant load of less than 50 in facilities having prompt or slow evacuation capability shall be not less than 36 in. (915 mm).7.7.2 Exit Discharge Through Interior Building Areas.Exits shall be permitted to discharge through interior building areas, provided that all of the following are met:(1) Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall discharge through areas on any level of discharge, except as otherwise permitted by one of the following:(a) One hundred percent of the exits shall be permitted to discharge through areas on any level of discharge in detention and correctional occupancies as otherwise provided in Chapters 22 and 23.(b) In existing buildings, the 50 percent limit on egress capacity shall not apply if the 50 percent limit on the required number of exits is met.(2) Each level of discharge shall discharge directly outside at the finished ground level or discharge directly outside and provide acces..