Starlight Assisted Living LLC

A licensure complaint, prompted by #CO39309 and #CO40534, was completed on 7/1/25. Deficiencies were cited. Based on interview and record review the residence failed to ensure the administrator and qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration records affecting 8 current residents. (Cross Reference S540, S1602)Findings include:On 7/1/25 at 8:00 a.m., the last two quarterly medication audits were requested from the residence however, it was not provided. On 7/1/25 at 11:38 a.m., the Administrator acknowledged that the residence had not completed medication audits. He added that the residence once a month medicaiton audit did not meet the the quarterly audit requirements. Based on interview and record review, the residence failed to ensure that each resident care plan reflected current personal services needs and preferences along with staff tasks necessary to meet the needs of the resident, affecting three of three sample residents (#1-#3) who required updates to the care plans. (Cross Reference S540)Findings include:1. Record ReviewResident #1 was admitted to the residence on 3/16/24 with diagnoses including opioid dependence, anxiety disorder and chronic pain syndrome.The residence provided a pre-admission assessment dated 3/19/24 for Resident #1, however, the residence did not create an individualized care plan for Resident #1. In.. Based on observation and interview, the residence failed to have a locked medication cart to store medications unattended by qualified medication administration persons or other licensed staff, affecting eight current residents. Findings include:1. Observation On 7/1/25 at 7:27 a.m., the medication cart was opened and left unattended. Staff #1 was observed serving breakfast to residents. On 7/1/25 during the onsite observation from 7:27 a.m. through 12:45 p.m., the medication storage cabinet where the residence stored the resident' s medication was unlocked. Two residents and one family member were observed walking past the unlocked medication cabinet. On 7/1/25 at 12:45 .. Based on observation, record review, and interview, the residence failed to ensure the administrator managed the day-to-day delivery of services, affecting 8 current residents. (Cross Reference S1150, S1604)Findings include: 1. References and Resident Agreementa. Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management, and maintenance of the assisted living residence. b. The residence' s March 2024 resident agreement, read in part, that the residence provided a safe and sanitary environment, personal services, and protect.. Based on record review, observation and interview, the residence failed to maintain a record on a separate sheet for each resident receiving a controlled substance which contains the name of the controlled substance, strength and dosage, date and time administered, resident name, name of authorized practitioner, and the quantity of the controlled substance remaining, affecting residents #1-#2. (Cross Reference S1604)Findings include: Resident #1 was admitted to the residence on 3/16/24 with diagnoses including opioid dependence, anxiety disorder and chronic pain syndrome.Written practitioner' s orders, dated 5/29/25, directed the residence to administer the following medicatio..

A certification complaint, prompted by #CO39310 and #CO40533, was completed on 7//25. Deficiencies were cited Based on interview and record review, the facility (residence) failed to ensure that each resident care plan reflected the Member ' s (resident) goals, choices, preferences, and needs and incorporation of these elements into the supports and services described in the Person-Centered Support Plan, affecting three of three sample residents (#1-#3) who required updates to the care plans. Findings include:1. Record ReviewResident #1 was admitted to the residence on 3/16/24 with diagnoses including opioid dependence, anxiety disorder and chronic pain syndrome.The residence provided a pre-admission assessment dated 3/19/24 for Resident #1, however, the residence did not create an individualized care plan for Resident #1. 2. InterviewOn 7/1/25 at approximately 11:35 a.m., the administrator of record failed to provide an individualized care plan and update the care plans based on residents' care preferences and services for residents #1. Additionally, record review and interview revealed similar deficient practice for Residents #2-#3.

A revisit survey was completed on 5/20/24 for all previous deficiencies cited on 10/07/2021. 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 was completed on 12/20/23. Deficiencies were cited. Based on record review and interview, the residence failed to ensure applicants completed the Colorado Adult Protective Data Systems (CAPS) requirements prior to hiring staff who provided direct care to at-risk residents for two of two sample staff (#1, #2).Findings Include:1. Referencesa. According to 2022 Colorado Revised Statutes (C.R.S.) Title 26 - Human Services Code Article 3.1 - 101 Protective Services for At-risk Adults - C.R.S 26-3.1-111. Access to CAPS - employment checks, read (1) The general assembly finds and declares that individuals receiving care and services from persons employed in programs or facilities described in subsection (7) of this section are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult. Subsection seven read (7) The following employers shall request a CAPS check pursuant to this sec.. Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting eight current residents.Findings include:1. References and residence policya. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that' s useful in many emergencies, such as a heart attack or near drowning, in which someone' s breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (5/1/21) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 b. According to the American Red Cross: "Obstructed Airway Care for Adults...If the patient is able to speak to you or is coughing forcefully: Encourage the patient to keep coughing but be prepared to clear the airway if the patient' s condition changes...Obtain consent...Perform abdominal thrusts...Perform alternate techniques-back blows, chest thrusts, or airway management...Continue to clear the airway ...If the patient becomes unresponsive, carefully lowe..