Tcal 2 LLC

A revisit survey was completed on 10/3/25 for previous deficiencies cited on 8/19/25. The agency is in compliance with all regulations surveyed. 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 revisit survey was completed on 10/3/25 for previous deficiencies cited on 8/19/25. The agency is in compliance with all regulations surveyed. 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 recertification survey was completed on 8/19/25. Deficiencies were cited. Based on observations, records review, and interviews, the residence failed to maintain a home-like environment, as evidenced by a bicycle lock on the refrigerator for 10 current residents. (Cross-reference B0158)An environmental tour on 8/19/25 at 7:10 a.m. revealed a U-shaped bicycle lock on the refrigerator, preventing access. An undated notice posted in the kitchen read: "The kitchen is closed after 8 PM because people keep leaving a big mess in the kitchen overnight".On 8/19/25 at 7:18 a.m., Resident #4 stated the bike lock was a problem and that they sometimes wanted to make food later than 8:00 p.m.On 8/19/25 at 2:45 p.m., the administrator designee stated that residents had acc.. Based on record review and interviews, the facility (residence) failed to specify the individual room and bed the member (resident) will occupy and the duration of the residency agreement for three of four sample residents (#1, #2, #3).Findings Include:The resident census, dated 7/29/25, indicated that Resident #1 resided in room number five, bed number one; Resident #2 resided in room number four, bed number one; and Resident #3 resided in room number six, bed number one.Resident #1 was admitted to the residence on 8/26/16 with a diagnosis of bipolar disorder, type one. A residency agreement, dated 9/24/20, signed by Resident #1, indicated that Resident #1 resided in room number fo.. Based on records review and interviews, the facility (residence) failed to allow access to food preparation and storage areas at all times for 10 current members (residents). (Cross-reference B1780)Findings Include:An environmental tour on 8/19/25 at 7:10 a.m. revealed a U-shaped bicycle lock on the refrigerator, preventing access. An undated notice posted in the kitchen read: "The kitchen is closed after 8 PM because people keep leaving a big mess in the kitchen overnight".On 8/19/25 at 7:18 a.m., Resident #4 stated the bike lock was a problem and that they sometimes wanted to make food later than 8:00 p.m.On 8/19/25 at 2:45 p.m., the administrator designee stated that residents had acc.. Based on records review and interviews, the facility (residence) failed to provide sufficient support to ensure the accurate recording of medication administration for two of four sample members (residents) (#2, #3).Findings Include:Resident #2 was admitted to the residence on 3/14/25 with diagnoses of diabetes mellitus, type one, and schizophrenia.A practitioner' s order, dated 4/8/25, directed the residence to administer to Resident #2 nicotine 14mg by topical patch every morning and remove the patch every evening for four weeks, then decrease to a 7mg topical patch. Nicotine 7mg by topical patch every morning and remove the patch every evening for four weeks. Clindamycin.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised that it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 Section 8.7000.8.7001.B Individual Rights under the Home and Community-Based Services (HCBS) Settings Final Rule3. Additional Criteria for HCBS Settings(a) Provider-Owned or -Controlled Residential Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification pro..

A relicensure survey was completed on 8/19/25. Deficiencies were cited. Based on observation, records review, and interviews, the residence failed to ensure residents had access to food and food storage areas at all times for 10 current residents.Findings Include:An environmental tour on 8/19/25 at 7:10 a.m. revealed a U-shaped bicycle lock on the refrigerator, preventing access. An undated notice posted in the kitchen read: "The kitchen is closed after 8 PM because people keep leaving a big mess in the kitchen overnight".On 8/19/25 at 7:18 a.m., Resident #4 stated the bike lock was a problem and that they sometimes wanted to make food later than .. Based on observations and interviews, the residence failed to keep the grounds free of garbage and rubbish for 10 current residents.Findings Include:An environmental tour on 8/19/25 at 7:06 a.m. revealed cleaning supplies, broken furniture, disassembled bicycles, and general rubbish on the grounds.On 8/19/25 at 1:50 p.m., Resident #1 stated he would like the grounds cleaned up.On 8/19/25 at 2:45 p.m., Staff #1 stated she would check the grounds for rubbish more often. On 8/19/25 at 2:45 p.m., the administrator designee stated she was unaware of the rubbish and had not.. Based on records review and interviews, the residence failed to comply with authorized practitioner orders for two of four sample residents (#2, #3). (Cross-reference U1600)Findings Include:Resident #2 was admitted to the residence on 3/14/25 with diagnoses of diabetes mellitus, type one, and schizophrenia.A practitioner' s order, dated 4/8/25, directed the residence to administer to Resident #2 nicotine 14mg by topical patch every morning and remove the patch every evening for four weeks, then decrease to a 7mg topical patch. Nicotine 7mg by topical patch every morn.. Based on records review and interviews, the residence failed to ensure resident agreements were amended to reflect current room assignments for three of four sample residents (#1, #2, #3).Findings Include:The resident census, dated 7/29/25, indicated that Resident #1 resided in room number five, bed number one; Resident #2 resided in room number four, bed number one; and Resident #3 resided in room number six, bed number one.Resident #1 was admitted to the residence on 8/26/16 with a diagnosis of bipolar disorder, type one. A residency agreement, dated 9.. Based on records review and interviews, the residence failed to ensure staff accurately documented each medication administration event at the time the event was completed for two of four sample residents (#2, #3). (Cross-reference U1568)Findings Include:Resident #2 was admitted to the residence on 3/14/25. The August 2025 MAR indicated that "staff plans to give this med later" for gabapentin and mirtazapine on 8/14 and 8/15.Resident #3 was admitted to the residence on 6/7/17. The July and August 2025 MARs indicated that "staff will give this med later" or "staff plans to g.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.(A) If the ..

A licensure complaint, prompted by #CO32194, was completed on 1/8/24. No deficiencies were cited 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 7.14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks:(H) Pre-pouring of medication14.15 The assisted living residence shall ensure each resident' s right to privacy and dignity with respect to medication monitoring and administration.

A licensure revisit was completed on 2/2/23 for all previous deficiencies cited on 9/23/22. Deficiencies were cited. Based on observations and interviews, the residence failed to keep the residence grounds free of garbage and rubbish, affecting nine current residents.This deficiency was cited previously during a state licensure survey 9/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 9/23/22 from 7:30 a.m. to approximately 10:30 a.m., the following was observed on the residence' s exterior grounds:One used twin mattress leaning against the side of the residence.An old gate leaning against the residence' s fence. A roll of chicken wire fencing leaning against the old gate. A broken plastic chair next to the garage door. An exercise pedal chair in the smoking area. On 1/23/23 at 7:53 a.m., Staff #1 stated the mattress had been on the side of the house for approximately one week. She confirmed the smoking area was in the back of the residence. On 2/2/23 at 8:18 a.m., Resident #5 was in the smoking area of the r.. Based on record review and interview, the residence failed to ensure its quality management program (QMP) contained the required elements, affecting nine current residents. This deficiency was cited previously during a state licensure survey 9/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator' s designee. b. Chapter II regulations governing health facilities, part 4.1.2A, requires the QMP to include the following elements:Identification of quality management projects For the client safety component of the program, the plan shall identify: a. The types of service delivery errors and potential for error that will be monitored, which shall be based, at minimum, on a review of negative resi.. Based on record review and interview, the residence failed to ensure its quality management program (QMP) implemented improvement strategies, affecting nine current residents. Findings include:This deficiency was cited previously during a state licensure survey 9/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator' s designee. b. Chapter II regulations governing health facilities, part 4.1.2B, requires the QMP to include the following elements:Implementation of improvement strategiesHow the improvement strategies would be developedDocumentation for each improvement strategy, to include: How information about patterns and trends will be shared with staff and how the underlying systemic proble..