Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adara Living during CMS and state inspections, most recent first.
Two residents were administered other residents' medications due to failures in verifying patient identity and following medication administration protocols. One resident was hospitalized after receiving antihypertensives and an opioid not prescribed to her, while another became lethargic after receiving his roommate's medications following a room switch that was not updated in the EMR. Both incidents were linked to staff not properly confirming resident identity and not adhering to established procedures.
A resident with severe cognitive and physical impairments, requiring a mechanical lift and two-person assistance for transfers, was improperly transferred by a new CNA who attempted a stand-pivot transfer alone after being misinformed about the resident's needs. This resulted in a fall and a significant skin tear. The CNA did not consult the care plan or nursing staff prior to the transfer, and staff interviews revealed communication gaps and limited access to care plan details.
Two residents experienced sexual abuse from another resident with a known history of sexually inappropriate behavior. Despite care plans outlining interventions such as 1:1 staff monitoring and frequent checks, these measures were not effectively implemented, resulting in repeated incidents where the perpetrator inappropriately touched other residents. Staff and resident interviews confirmed that the facility did not adequately identify or address the risk, leading to substantiated abuse events.
The facility failed to maintain sanitary conditions in nourishment refrigerators, as observed in five instances where food items were not labeled with resident names or expiration dates. Med-Pass containers, energy drinks, and other food items were improperly stored, and a sticky substance with hair was found in one refrigerator. Staff interviews revealed inadequate labeling practices and monitoring of refrigerator contents.
The facility failed to implement its policy on food storage brought by visitors, leading to unsafe conditions in resident refrigerators. Observations showed missing thermometers and improper temperature monitoring, with no corrective actions documented. Staff interviews revealed confusion over responsibilities, and resident interviews highlighted unclean conditions and undated food items.
The facility failed to provide annual training on abuse prevention and dementia management to 46 and 42 staff members, respectively. The transition to a new training platform did not ensure completion of mandatory training, as revealed by interviews with the NHA and DON. Despite efforts to audit training records, the facility could not confirm all staff had completed the necessary training.
A facility failed to protect residents from abuse, leading to multiple physical altercations. A resident with a history of traumatic brain injury and dementia slapped another during a wheelchair collision. Another resident with Alzheimer's and PTSD was involved in several altercations, including striking a resident and pushing another to the ground. Despite interventions like 15-minute checks, the facility's investigations often unsubstantiated abuse due to lack of intent to harm, highlighting inadequate monitoring and personalized care plans.
A resident with schizophrenia and PTSD was left exposed while using the restroom, as both the room and bathroom doors were open, making him visible from the hallway. Staff members failed to ensure privacy, with one CNA walking past without closing the door and another leaving the room with a trash bag, leaving the door open. Interviews revealed that staff were trained to ensure privacy, but this was not consistently applied.
A resident with multiple allergies experienced issues with laundry services at an LTC facility. Despite the resident's wife's request to handle the laundry due to allergy concerns, the facility failed to consistently store the resident's laundry for her. This led to missing clothing and the use of inappropriate detergents, risking the resident's health. Staff turnover and communication issues contributed to the deficiency.
A facility failed to accurately reflect a resident's hospice status in the MDS assessment. The resident, with COPD and heart failure, was incorrectly coded as receiving hospice care, despite no supporting documentation in the EMR. The MDSC acknowledged the error and corrected it during the survey.
The facility failed to provide adequate respiratory care for two residents using CPAP machines. One resident had no cleaning schedule or care plan for their CPAP, while another had a non-functional machine due to a missing power cord and improper storage of the mask and tubing. Staff interviews revealed confusion about cleaning responsibilities and storage methods.
A facility failed to follow proper procedures before using bed rails for a resident with quadriplegia, leading to a deficiency. The resident was observed with half bed rails up without a signed consent or a PT/OT safety evaluation. The facility did not document attempts to use alternatives or obtain a physician's order for the bed rails. Staff interviews revealed a lack of awareness and adherence to policies, as the resident had arranged for a new bed from the VA without notifying the DON and NHA.
The facility failed to provide meals in accordance with mechanically altered diet restrictions, serving residents on a mechanical soft diet oven-roasted potatoes with skins, contrary to the facility's diet manual. This occurred due to a lack of adherence to dietary protocols and inconsistent communication among staff.
A facility failed to maintain accurate medical records for a resident, specifically regarding wound treatment orders. The resident had a left buttock pressure injury, but the treatment administration record incorrectly documented treatment for a right buttock wound. Despite nurses being aware of the correct wound location, the error in documentation persisted until the survey.
Failure to Prevent Significant Medication Errors
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration procedures. One resident with diagnoses including dementia, respiratory failure, and thrombocytopenia was given another resident's medications, which included antihypertensives and an opioid, resulting in acute changes in condition such as low blood pressure, decreased responsiveness, and lethargy. The resident attempted to alert the nurse that the medication cup did not have her name, but the nurse insisted the medications were correct. The resident subsequently took the medications, became increasingly lethargic, and was sent to the hospital, where she was treated for accidental overdose and recovered after receiving Narcan. Another resident, with a history of malnutrition, hypertensive heart disease, and traumatic brain injury, received his roommate's medications after the two switched sides of their shared room without the change being updated in the electronic medical record (EMR). The nurse administering medications did not verify the residents' identities using updated photos or other identifiers, resulting in the resident receiving the wrong medications. This resident became unusually lethargic and was monitored closely after the error was discovered. The error was identified when the roommate reported that the nurse had attempted to give him morphine, which he did not take, and that his roommate had received a large number of pills. In both cases, the medication errors were directly linked to failures in verifying resident identity and following established medication administration protocols. Staff interviews confirmed that the nurses involved did not consistently use the required checks, such as confirming the resident's name, photo, or other identifiers, before administering medications. The errors were further compounded by issues such as pre-pouring medications and not updating room assignments in the EMR, which contributed to the confusion and subsequent administration of incorrect medications.
Failure to Prevent Accident Due to Improper Transfer
Penalty
Summary
The facility failed to prevent an accident involving a resident who required a mechanical lift and two-person assistance for transfers due to severe cognitive impairment, left hemiplegia, and other significant medical conditions. According to the care plan and physician orders, the resident was to be transferred using a Sara lift with the help of two staff members. However, a certified nurse aide (CNA) who was new to the facility attempted to transfer the resident alone using a stand-pivot method after being informed by a registered nurse (RN) that the resident was a one-person assist and able to stand and pivot. The CNA was unaware of the resident's actual transfer requirements and did not review the care plan or consult with nursing staff prior to the transfer. During the transfer, the resident fell, resulting in a 7 cm skin tear on the left lower leg with active bleeding. The incident report identified gait imbalance as a predisposing factor and noted that the CNA was not aware that a mechanical lift and additional assistance were required. The resident's care plan, which documented the need for a Sara lift and two-person assistance, was not accessed or referenced by the CNA prior to the transfer. The CNA also reported that the resident refused the mechanical lift and requested a stand-pivot transfer, which was performed without proper authorization or support. Interviews with staff revealed gaps in communication and access to care plan information. The director of nursing (DON) stated that transfer statuses and mechanical lift requirements were documented in care plans, but CNAs did not have full access to these documents and were expected to ask nurses for clarification. The DON also indicated that the CNA did not seek guidance before performing the transfer. The incident highlighted a breakdown in communication regarding the resident's transfer needs and a lack of adherence to established protocols for safe resident handling.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, resulting in substantiated incidents of abuse. In the first incident, a resident with a history of sexually inappropriate behaviors and a diagnosis of severe traumatic brain injury grabbed another resident's shirt and upper chest area, attempting to touch her breast. Multiple staff and a dietary aide witnessed the event, and the victim reported feeling unsafe and uncertain about the perpetrator's intentions. The care plan for the perpetrator included interventions such as one-to-one staff monitoring and frequent checks, but these measures were not effectively implemented prior to the incident. In a separate incident, the same resident touched another resident's breast twice while she was assisting him with pudding. The victim, who had severe cognitive impairments and a diagnosis of dementia, reported the incident to the nursing home administrator. The perpetrator admitted to the behavior, and staff confirmed that the two residents had been interacting at the time. Prior to this event, the facility was aware of the perpetrator's history of sexual behaviors but had not implemented more restrictive interventions to prevent further incidents. Interviews with staff and residents confirmed that the facility's interventions were insufficient to prevent the abuse. The facility's abuse policy required maintaining an environment free from abuse and ensuring staff distribution and knowledge to meet residents' needs. However, the facility did not adequately identify or address the risk posed by the resident with a history of sexually inappropriate behavior, leading to repeated incidents of sexual abuse involving vulnerable residents.
Facility Fails to Maintain Sanitary Conditions in Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure food was prepared, distributed, and served under sanitary conditions in five nourishment refrigerators. Observations revealed that the facility did not label Med-Pass containers with an opened or expiration date according to the product's handling instructions. Additionally, a Monster energy drink was found without a resident's information to differentiate it from staff food. A sticky light brown substance with long black hair was also observed at the bottom of one refrigerator. Further observations showed that a refrigerator on the second floor contained a Med-Pass container that was not labeled with an opened or expiration date. On the third floor, three Nestle Boost supplements were found with a use-by date, and a secure unit freezer contained an unlabeled and uncovered medication cup with a frozen white substance. Another refrigerator on the third floor secure unit contained several items, including a Med-Pass container, fresh blueberries, coffee mate creamer, hand sanitizer, salsa, a Starbucks cup, and a Red Bull can, none of which were labeled with resident names or expiration dates. Interviews with staff revealed that dietary aides and CNAs were responsible for labeling food items brought in by residents' families. The NHA and DON stated that both dietary and nursing staff monitored refrigerator temperatures and checked for expired products. However, the Med-Pass supplement was not widely used, and opened containers were typically placed in refrigerators without proper labeling. The NHA emphasized that staff food or drinks found in resident refrigerators would be discarded, as these refrigerators were designated for resident food only.
Failure to Implement Food Storage Policy in Resident Refrigerators
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary conditions on two of three floors. Observations revealed that personal refrigerators in residents' rooms lacked internal thermometers, and temperatures were not consistently monitored or recorded. Some refrigerators were found to have temperatures above the acceptable range of 41 degrees Fahrenheit, with no corrective actions documented. Additionally, food items in these refrigerators were not properly labeled with the resident's name and date, as required by the facility's policy. Interviews with staff, including a certified nurse aide and the nursing home administrator, indicated a lack of clarity and consistency in monitoring the temperatures of residents' personal refrigerators. The housekeeping staff was responsible for recording temperatures during room cleaning, but there was confusion about who was responsible for monitoring and taking corrective actions when temperatures were out of range. The environmental services director mentioned that thermometers were recently ordered to address the issue, but it was unclear if staff had been adequately trained on the policy. Resident interviews and observations further highlighted the deficiencies. One resident reported that her refrigerator had not been cleaned since she moved in two years ago, and observations confirmed the presence of food spills and ice build-up. Another refrigerator was found with undated food items and no thermometer inside. These findings demonstrate a failure to ensure safe and sanitary storage of food items in residents' personal refrigerators, as required by both the facility's policy and state regulations.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to provide mandatory annual training on abuse prevention and dementia management to a significant portion of its staff. Specifically, 46 out of 212 staff members did not complete the required annual abuse prevention training, and 42 out of 212 staff members did not complete the annual dementia management training. This deficiency was identified through a review of training records and staff interviews, which revealed that the facility's previous electronic education platform was not effectively utilized by staff, leading to incomplete training. The facility had recently transitioned to a new training platform, but the transition did not ensure that all staff members completed the necessary training. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) highlighted that the facility had identified issues with training completion and had implemented a performance improvement plan (PIP) for human resources. However, this PIP did not address the annual abuse and dementia education. The NHA acknowledged the importance of ensuring all staff are trained to recognize signs of abuse and manage dementia care effectively. Despite efforts to audit and update training records, the facility was unable to provide documentation confirming that all staff had completed the required training.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, resulting in multiple incidents of resident-to-resident physical altercations. Resident #98, with a history of traumatic brain injury and dementia, exhibited physically aggressive behaviors towards others, including slapping Resident #16 during a wheelchair collision. Despite interventions such as 15-minute checks and behavior monitoring, the facility's investigation unsubstantiated the abuse due to Resident #98's poor impulse control, although the slap was acknowledged. Resident #127, diagnosed with Alzheimer's disease and PTSD, was involved in multiple altercations. On one occasion, Resident #127 struck Resident #67 after becoming agitated by obscenities, resulting in a laceration above Resident #67's eyebrow. Another incident involved Resident #106, who wandered into Resident #127's room and was pushed to the ground by Resident #127. The facility's investigations often concluded that abuse was unsubstantiated due to lack of intent to harm or absence of serious injury, despite evidence of physical altercations. The facility's failure to implement effective interventions and personalized care plans contributed to these incidents. Residents with known aggressive behaviors and cognitive impairments were not adequately monitored or separated to prevent conflicts. The facility's investigations frequently cited overstimulation and lack of intent as reasons for unsubstantiating abuse, overlooking the need for proactive measures to ensure resident safety and prevent further incidents.
Failure to Ensure Resident Privacy During Restroom Use
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident while using the restroom. The resident, who is over 65 years old and has diagnoses including schizophrenia and PTSD, was observed sitting on the toilet with both the room and bathroom doors open, making him visible from the hallway. Despite being cognitively intact and requiring assistance for toileting hygiene, the resident was left exposed, and staff members did not take appropriate actions to ensure his privacy. During the incident, an unidentified CNA walked past the resident's room without closing the door or checking on the resident. Another CNA exited the resident's room with a trash bag, leaving the door open, further exposing the resident. Interviews with CNAs revealed that they were trained to ensure privacy by closing doors unless the resident had specific needs, such as claustrophobia. The DON confirmed that the resident was generally comfortable with the bathroom door open unless visitors were present, indicating a lack of consistent privacy measures.
Failure to Honor Resident's Laundry Preferences Due to Allergies
Penalty
Summary
The facility failed to honor a resident's choice for laundry services, specifically for a resident with multiple allergies. The resident's wife had requested that the resident's dirty laundry be stored and saved for her to launder due to his allergies to most commercial laundry products. Despite this request, the facility did not consistently ensure that the resident's laundry was saved for his wife, leading to instances where the resident's clothes were missing or mixed with other residents' clothing. The resident, who was severely cognitively impaired and had a history of exposure to Agent Orange, suffered from multiple allergies, including allergies to certain laundry detergents. His wife reported that he had developed rashes in the past when the wrong soap or detergent was used. The facility's failure to consistently store the resident's laundry for his wife to launder was a significant oversight, especially given the resident's allergy-related health concerns. Interviews with facility staff revealed that there was a lack of consistent communication and adherence to the resident's laundry preferences. Although signs were posted in the resident's room to indicate his wife's preference to do his laundry, staff turnover and communication issues contributed to the failure to honor this request. The facility's policy on promoting resident self-determination was not effectively implemented in this case, as evidenced by the resident's missing clothing and the lack of documentation addressing his allergies and laundry preferences in his electronic medical record.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding hospice services. Resident #83, a 66-year-old individual with diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure, was reported in the MDS assessment as receiving hospice care. However, a comprehensive review of the resident's electronic medical record (EMR) did not reveal any physician's order for hospice, progress notes, or care-planned interventions indicating that hospice services were being provided. Interviews with facility staff revealed that the MDS Coordinator (MDSC) was responsible for completing the MDS assessments and acknowledged that the coding error occurred. The MDSC stated that she typically assessed residents in their rooms and consulted with staff to complete the MDS assessments. She admitted that the hospice services were incorrectly coded for Resident #83 and that the error was corrected once it was brought to her attention during the survey. The MDSC also mentioned that she planned to be more cautious in reviewing alerts in the future to prevent similar errors.
Inadequate Respiratory Care for Residents Using CPAP Machines
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required the use of CPAP machines. Resident #45 did not have a routine cleaning schedule for their CPAP machine, and there was no care plan in place that included the route of administration, oxygen supplementation, storage, cleaning, and machine settings. The resident reported that they had to clean their CPAP machine themselves, indicating a lack of staff involvement in maintaining the equipment. Resident #95's CPAP machine was non-functional due to a missing power cord, which had not been replaced despite being ordered a month prior. The resident had not used the CPAP machine in two to three years and reported that the machine and mask had not been cleaned since moving into the facility. Observations showed the CPAP mask and tubing were improperly stored, often found on the floor or under a fan, which could lead to contamination. Interviews with staff revealed a lack of clarity and adherence to the facility's policies regarding the cleaning and maintenance of CPAP machines. The night nurses were reportedly responsible for cleaning the equipment, but there was confusion about the frequency and proper storage methods. The director of nursing was unaware of the non-functional status of Resident #95's CPAP machine and the potential risks associated with improper use and maintenance of the equipment.
Failure to Follow Bed Rail Procedures for Resident
Penalty
Summary
The facility failed to ensure proper procedures were followed before the use of bed rails for a resident, leading to a deficiency. The resident, who was under 65 years old and diagnosed with quadriplegia and pressure ulcers, was observed with half bed rails in the up position on multiple occasions. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15 out of 15, the facility did not obtain a signed consent from the resident or their representative prior to the initiation of the side rails. Additionally, there was no evidence of a physical therapy or occupational therapy safety evaluation conducted before the use of the half bed rails on a new bed. The facility's policy required a comprehensive assessment and documentation of least restrictive alternatives before using physical restraints like bed rails. However, the facility did not document attempts to use alternatives or discussions about the potential elimination of the side rails. The resident was totally dependent on staff for bed mobility, contradicting the facility's documentation that the bed rails were not a restraint because the resident was paralyzed. Furthermore, the facility failed to obtain a physician's order for the use of bed rails, as the existing order did not specify the bed rails' position when staff was not repositioning the resident. Interviews with staff revealed a lack of awareness and adherence to the facility's policies regarding bed rail use. The NHA was unaware that bed rails were being used for the resident, and the DON stated that the facility did not practice using bed rails. The resident had arranged for a new bed from the VA, which was delivered and used without notifying the DON and NHA. The facility's failure to follow its policies and procedures for bed rail use, including obtaining necessary consents, evaluations, and orders, led to the deficiency identified during the survey.
Failure to Adhere to Mechanically Altered Diet Restrictions
Penalty
Summary
The facility failed to ensure that residents who were prescribed mechanically altered diets received food prepared according to their specific dietary needs. During meal service observations, it was noted that residents on a mechanical soft diet were served oven-roasted potatoes with skins, which were not in compliance with the dietary restrictions outlined in the facility's diet manual. The manual specifically restricted potato skins for residents on mechanically altered diets, yet the meal trays included potatoes with skins. The facility's policy on Therapeutic Diet Orders mandates that residents receive food in the appropriate form as prescribed by a physician or assessed by the interdisciplinary team. However, during the meal service, the dietary staff did not adhere to these guidelines, resulting in the improper preparation and serving of meals. The human resources director, who was previously the dietary manager, acknowledged the error and noted that potatoes without skins were served in other dining rooms, indicating a lapse in consistency and oversight in meal preparation. Interviews with the dietary manager and the nursing home administrator revealed a lack of clarity and communication regarding the dietary restrictions for mechanically altered diets. The speech therapist was consulted but provided conflicting information about the acceptability of potato skins for residents on a mechanical soft diet. Despite the facility's diet manual clearly restricting potato skins, the oversight led to the serving of inappropriate food items to residents, highlighting a breakdown in adherence to dietary protocols.
Inaccurate Wound Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurately documented medical records for a resident, specifically regarding wound orders and treatment records. The resident, over 65 years old, was admitted with diagnoses including post-surgical aftercare of the skin and multiple pressure ulcers. The resident was cognitively intact and required varying levels of assistance for daily activities. A discrepancy was found in the resident's electronic medical record (EMR) where a skin/wound note documented a right upper buttock unstageable pressure injury, but later corrected to a left buttock unstageable pressure injury. Despite this correction, the treatment administration record continued to reflect treatment for a right buttock wound until updated during the survey. The director of nursing (DON) confirmed that the nurses responsible for the resident's wound care were aware of the correct wound location on the left buttock but did not recognize the error in the treatment orders. The admission wound location chart, which was undated, incorrectly documented a wound on the right buttock. This inconsistency in documentation and failure to update the treatment orders in a timely manner led to the deficiency identified during the survey.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 597 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Broomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center At Northridge, Llc, The | 2.8 mi | ★★★★★ | 0 | 0 |
| Coal Creek Post Acute & Assisted Living | 3.6 mi | ★★★★★ | 14 | 0 |
| Malley Transitional Care Center | 4.2 mi | ★★★★★ | 2 | 0 |
| Village Care And Rehabilitation Center, The | 4.9 mi | ★★★★★ | 0 | 0 |
| Thornton Care Center | 5.6 mi | ★★★★★ | 3 | 0 |
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