Cozy Country Care LLC

SUMMARY OF FINDINGS:On 10/17/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Staff discovered an envelope of cash missing from client (A)’s locked medication cabinet, which was only accessible by nursing staff. During the course of the investigation, the healthcare entity conducted a search and interviews and notified the police. Several staff and managers confirmed the money had been secured in the cabinet on 10/11/25. The money was not found, and an alleged perpetrator could not be identified. Management reimbursed the client. Staff and clients were reminded about options to safeguard money and where money will be secured. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 1/7/2026 · released to the public 1/14/2026.

SUMMARY OF FINDINGS:On 8/6/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Client (B) alleged staff provided care in a rushed manner causing her pain. Also, client (B) said when she voiced being in pain, the staff allegedly told her to be “quiet.” During the course of the investigation, the healthcare entity ensured the staff members were not on the work schedule, conducted an assessment and interviews, and notified the police. The facility identified that staff’s techniques caused pain to the client’s legs, and it was determined not to be intentional or reckless. Staff denied making comments about disregarding her pain. No other clients reported having any concerns of staff mistreatment. An abuse event could not be substantiated. Education was provided to staff regarding mobility and transfers, and they were instructed to slow down with care. Staff requested a medical review for pain management with client (B). This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 9/29/2025 · released to the public 10/6/2025.

Summary of Findings:On 1/23/24, nurse (2) discovered a discrepancy between the narcotic count sheet and bubble pack number of medications. One tablet of 15 mg Oxycodone medication was missing. Through staff interviews and review of documentation, nurse (1) was unable to account for the documentation discrepancy with the Oxycodone. There was no reported harm to any residents. The following shift, nurse (1) did not show up or call off. The facility concluded one tablet of Oxycodone was unaccounted for and there was high suspicion of nurse (1) diverting the medication. Management terminated nurse (1)'s employment and contacted their licensing oversight board. In-services occurred with nursing staff on the narcotic policy and medication administration. Management continued monitoring staff compliance through random audits. Department Findings:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Sent to facility 11/18/2024 · released to the public 11/25/2024.

Summary of Findings:On 12/14/23 during morning shift, a nurse discovered 90 tablets of 15 mg Oxycodone medication missing along with the associated narcotic count sheets. Medications were secured in a double locked medication cart; accessible only by nursing staff. The medications had been prescribed to resident (B). Upon assessment, there were no reported adverse findings to resident (B) regarding pain management. The physician ordered more medications, which the facility paid for. The facility was unable to identify when the medication went missing or identify the alleged assailant. The allegation of a drug diversion was substantiated. All nursing staff received re-training on securing medications and protocols to follow with medication administration. Management implemented an auditing plan to monitor compliance with nursing staff and medication accountability. Department Findings:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Sent to facility 11/18/2024 · released to the public 11/25/2024.