Stephens Farm at Adeo Colorado

A licensure complaint, prompted by #CO41065 and #CO41770, was completed on 3/4/26. Deficiencies were cited. Based on record review and interview, the residence failed to ensure appropriate routine staffing levels considering the acuity and needs of the residents and services set forth in the resident agreement, affecting 13 current residents. (Cross-reference U1634)Findings include:1. Residence PolicyThe residence' s undated Resident Agreement, read in part: services provided included 24-hour on-site qualified medication administration personnel (QMAP). 2. Record reviewJanuary and March 2026 staff schedules, dated 2/8-3/7/26, revealed the following shifts did not have a QMAP on duty: 11:00 p.m. to 7:00 a.m. on 2/9-2/11, 2/15, 2/17-2/25, 2/28, 3/1, 3/3 and 3/4/26.3. InterviewOn 3/4/26 at approximately 2:45 p.m., the administrator acknowledged not having a QMAP scheduled for all shifts. The administrator stated that all current residents were prescribed at least one medication on an as-needed basis (PRN). The administrator stated that a non-QMAP staff had to call a separately licensed residence for a QMAP to come and a.. Based on record review and interview, the residence failed to ensure that two qualified medication administration persons (QMAPs) jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time the count occurred, affecting three of four sample residents (#1, #2, and #4). (Cross-reference U0720)Findings include:A review of the controlled substance shift count document, dated 1/1/26 through 3/4/26, revealed multiple dates where only one of two staff members, who signed off on the controlled substance count, were certified as qualified medication administration persons (QMAPs). Additionally, the controlled substance shift count document, dated 1/1/26 through 3/4/26, revealed the following:Resident #1 received Lorazepam 0.5 Mg Tablet 3 Times Daily;Resident #2 received Lorazepam 0.5 Mg Tablet 3 Times Daily; and, Resident #4 received Lacosamide 200 Mg Tablet twice daily.On 3/4/26 at approximately 2:50 p.m., the administrator acknowledg.. Based on record review and interviews, the residence failed to include the possible actions taken if any of the house rules were knowingly violated by a resident, affecting one of four sample residents (#2).Findings include:1. House rulesThe residence' s "House Rules" policy dated June 2025 read in part: "Residents shall understand and follow posted House Rules and be aware of possible actions that could be taken if rules are broken. Violation of House Rules may result in discharge from the program. You may not smoke inside any area of the building. Smoking is allowed outside in the designated Smoking Areas. You will be redirected to the designated smoking area if you are found smoking in these prohibited areas. Smoking inside the building is grounds for eviction." 2. Record reviewResident #2 was admitted to the residence on 4/2/25, with a diagnosis of a traumatic brain injury (TBI).An incident report, which was the same as the residence' s progress notes, dated 2/3/26 at 7:30 p.m., read staff asked Resident #2 for her electronic cigarette b..

A supportive living program complaint, prompted by #CO41062 and #CO41771, was completed on 3/4/26. A deficiency was cited. Based on record review and interview, the facility (residence) failed to ensure appropriate routine staffing levels considering the acuity and needs of the members (residents) and services set forth in the resident agreement, affecting 13 current residents. Findings include:1. Residence PolicyThe residence' s undated Resident Agreement, read in part: services provided included 24-hour on-site qualified medication administration personnel (QMAP). 2. Record reviewJanuary and March 2026 staff schedules, dated 2/8-3/7/26, revealed the following shifts did not have a QMAP on duty: 11:00 p.m. to 7:00 a.m. on 2/9-2/11, 2/15, 2/17-2/25, 2/28, 3/1, 3/3 and 3/4/26.3. InterviewOn 3/4/26 at approximately 2:45 p.m., the administrator acknowledged not having a QMAP scheduled for all shifts. The administrator stated that all current residents were prescribed at least one medication on an as-needed basis (PRN). The administrator stated that a non-QMAP staff had to call a separately licensed residence for a QMAP to come and administer PRN medications if a resident made a request.

A revisit survey was completed on 2/15/24 for all previous deficiencies cited on 12/20/23. No 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

A supportive living program recertification survey was completed on 12/20/23. A deficiency was cited. 8.515.85.D PROVIDER LICENSING AND CERTIFICATION REQUIREMENTS 1. To be certified as an SLP provider, the entity seeking certification must be licensed by CDPHE as an Assisted Living Residence (ALR) pursuant to 6 CCR 1011-1, Ch. 7, except as provided below.a. Subject to Department approval, providers that have been in continuous operation at the same address prior to 1987 may continue to furnish SLP services under a Home Care Agency (HCA) license pursuant to 6 CCR 1011-1, Ch. 26 instead of the ALR license. ii. Providers furnishing SLP services under a Department-approved exception are required to comply with the medication administration requirements pursuant to both the HCA licensure requirements found at 6 CCR 1011-1, Chapters 7 and 26, and Section 25-1.5-301 through 304, C.R.S. 6 CCR 1011-1, Ch. 7, Section 14, (2018) is hereby incorporated by reference.Based on interview and record review, the facility (residence) failed to comply with the medication administration requirements pursuant to both the HCA licensure requirements found at 6 CCR 1011-1, Chapters 7, affecting three of three sample participants (residents) (#1, #6, #7). Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 14.11, requires the assisted living residence shall ensure only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.Chapter VII regulations governing assisted living residences, part 14.17, requires the assisted living residence shall ensure that each authorized practitioner ' s order for medication includes ... the signature of the practitioner.The residence ' s Medication Administration policy, dated 1/1/16, read in part that the residence administered medications only under current written order from a licensed physician or other authorized practitioner. 2. Resident #1 was admitted to the residence on 3/12/19 with a traumatic brain injury, high risk of aspiration, spastic quadriparesis, anxiety, muscle spasticity, chronic headaches, a..

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 712.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach;12.15 The assisted living residence shall develop policies and proc.. A relicensure survey was completed on 12/20/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that only medications ordered and signed by an authorized practitioner were prepared for and administered to residents, affecting three of three sample residents (#1, #6, #7). Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 14.17, requires the assisted living residence shall ensure that each authorized practitioner' s order for medication includes ... the signature of the practitioner.The residence' s Medication Administration policy, dated 1/1/16, read in part that the residence administered medications only under current written order from a licensed physician or other authorized practitioner. 2. Resident #1 was admitted to the residence on 3/12/19 with a .. Based on observation, record review, and interview, the residence failed to ensure a name-based criminal history report was requested prior to hire and conducted by the Colorado Bureau of Investigation (CBI) for two of three sample staff (#10, #11), affecting 17 current residents.Findings include:The residence' s Background Check policy, dated 1/1/16, read in part that the residence conducted criminal background checks; however, the policy failed to contain that the residence required that the name-based criminal history report was conducted by the CBI.On 12/20/23, from approximately 7:00 a.m. until 4:00 p.m., Staff #10 worked as a personal care worker (PCW) at the residence. On 12/20/23, from approximately 3:00 p.m. until 5:00 p.m., Staff #11 worked as a PCW at the residence. .. Based on observation, record review, and interview, the residence failed to ensure staff who assisted in feeding a resident shall be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional to assess choking risk, affecting four of four sample staff (#1, #7, #10, #11) who assisted one sample resident (#1).Findings include:1. ReferenceAccording to the Mayo Clinic: "Pureed foods can be made at home as well; your favorite dishes simply must be run through a blender or food processor, then a fine-wire strainer to avoid large chunks." Mayo Clinic Health System (2023) Powerful Puree, retrieved from: https://connect.mayoclinic.org/blog/weight-management-1/newsfeed-post/powerful-purees/2. Resident #1 was ad..

A complaint revisit was completed on 12/20/23 for all previous deficiencies cited on 2/14/22. A deficiency was cited. Based on observation, record review, and interview, the residence failed to ensure staff who assisted in feeding a resident shall be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional to assess choking risk, affecting four of four sample staff (#1, #7, #10, #11) who assisted one sample resident (#1).This deficiency was cited previously during a state licensure survey 2/14/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ReferenceAccording to the Mayo Clinic: "Pureed foods can be made at home as well; your favorite dishes simply must be run through a blender or food processor, then a fine-wire strainer to avoid large chunks." Mayo Clinic Health System (2023) Powerful Puree, retrieved from: https://connect.mayoclinic.org/blog/weight-management-1/newsfeed-post/powerful-purees/2. Resident #1 was admitted to the residence on 3/12/19 with a traumatic brain injury, high risk of aspiration, and chronic bronchitis.a. ObservationOn 12/20/23 from 10:17 a.m. until 10:50 a.m., Staff #10 assisted Resident #1 with eating breakfast. The staff member asked the resident the amount of thickening agent he wanted, and he communicated that he wanted a tablespoon. The staff member stated that seemed like too much. She sprinkled a quarter of a tablespoon and mixed it into the food twice. The staff member demonstrated the thickness of the pureed breakfast by lifting the spoon and allowing the puree to drip into the bowl. The pureed food appeared to be approximately the thickness of honey. b. Record ReviewThe care plan for Resident #1, dated 1/31/23, read in part that residence staff assisted the resident with eating pureed food which was the consistency of applesauce.The personnel files for Staff #7, #10, and #11, contained documentation of training by a registered nurse regarding the use of hydration with the feeding tube for R..