Tammy and Martys Cozy Adult Care Home II LLC

A Licensure survey, prompted by #CO40449 was completed on 9/23/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure a comprehensive assessment was completed, documented in writing, and establish an individualized care plan at the time of move-in, affecting one of three samp.. Based on interview and record review, the residence failed to ensure the resident care plan promoted resident safety and detailed specific personal service needs along with the staff tasks necessary to meet those needs, affecting one .. Based on interview and record review, the residence failed to provide quarterly basis audits ensuring accuracy, complete medication administration records, medication error reports, and controlled substance lists, affecting thre.. Based on interview and record review, the residence failed to review annually and update policies and procedures, affecting 11 current residents. Findings include: On 9/23/25 at 7:30 a.m., the following policies were requested: Ad.. Based on observation and interview, the residence failed to ensure it had a fire-resistant waste disposal container in the designated smoking area, affecting 11 current residents. Findings include: On 9/23/25 at approximately 7:40 a.m.. Based on observation and interview, the residence failed to keep the ramps in good repair, affecting 11 current residents. Findings include: On 9/243/25 at approximately 7:45 a.m., an environmental tour revealed the residence .. Based on record review and interview, the residence failed to ensure that all staff who are certified in cardiopulmonary resuscitation (CPR) provide those services in accordance with their training, affecting all 11 current.. Based on record review and interviews, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 11 current residents.Findings Include:On 9/23/25, at approxima.. Based on record review and interviews, the residence failed to have emergency policies addressing all required elements, affecting 11 current residents.Findings include:1. Record ReviewThe residence ' s undated Emergency Man.. Based on record review, observations, and interviews, the residence failed to comply with the Colorado Clean Air Act at Sections 25-14-201 through 25-14-209 C.R.S, affecting 11 current residents. Findings include:1. Observations On 9/.. Based on records review and interviews, the residence failed to ensure resident agreements were reviewed annually, affecting one of three (#2) sample residents.Findings Include:Resident #2 was admitted to the residence on 8/1/21 w.. 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 a..

A certification survey, prompted by #CO40450 was completed on 9/23/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to ensure a residency agreement that specified the duration of the agreement was in place for each member (resident), affecting one of three sample members (#2). Findings Include:Member #2 was admitted to the residence on 8/1/21 with a diagnosis including anxiety and depression. A residency agreement, dated 8/1/21, was the only residency agreement provided on 9/23/25, and did not specify the duration of the agreement.On 9/23/25, at approximately 3:00 p.m., the owner stated he was unaware residency agreements should be updated annually or amended as necessary. The owner acknowledged the residency agreement for Member #2, dated 8/1/21, did not specify the duration of the agreement, was not updated annually, .. Based on interview and record review, the facility (residence) failed to ensure the member (resident) care plan promoted resident safety and detailed specific personal service needs along with the staff tasks necessary to meet those needs, affecting one of three sample residents (#2). Findings include: Resident #2 was admitted to the residence on 7/1/25 with diagnoses including dementia and amnesia. During the on-site visit on 9/23/25, the administrator created and submitted the individualized care plan for Resident #2. The care plan for Resident #2 read that the resident was diagnosed with dementia and amnesia, and to make sure the resident did not wander off. However, the care plan did not contain detailed, specific personal service needs or staff tasks to meet the resident' s needs. On 9/2.. Based on observations and interviews, the facility failed to maintain a home-like quality and feel for members at all times, affecting 11 current members.An environmental tour of the facility on 9/23/25, beginning at 7:30 a.m., revealed a note posted on the community refrigerator addressed to all staff which read, "I have been active on cameras and all I see is staff in the restrooms ..." This note was located directly above a note reminding Member #1 not to eat fish or chicken. A note, located on the sliding glass door of a back patio, read " ...If I find out you are smoking on this patio, it will be automatic eviction for resident..."On 9/23/25, at approximately 8:00 a.m., Member #1 stated staff posted notes for him around the facility so he can be reminded of what he needs to do. Member #1 went .. Based on record review and interviews, the agency failed to protect the right to privacy and dignity by failing to provide a key to the bedroom for two (#1-#2) of three sample members.Findings include:1. Record ReviewA lease agreement for Member #2, dated 8/1/21, revealed he would reside in a room located downstairs, but did not indicate a room number. The agreement further read that Member #2 would be assigned a key to the room.A lease agreement for Member #1, dated 7/1/25, revealed Member #1 would be assigned a key to room number eight.2. InterviewsOn 9/23/25, at approximately 8:30 a.m., Member #2 acknowledged she did not use a key to get into her room or to get into the facility. On 9/23/25, at approximately 8:20 a.m., Member #1 stated the members at the facility did n..

A revisit survey was completed on 05/23/23 for all previous deficiencies cited on 11/01/22. The facility is in compliance with all deficiencies 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