Adara Living

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Smoke Deficiencies

Construct fire resistant interior walls.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Based on record review and interviews, the facility failed to ensure two (#4 and #2) of three residents reviewed for abuse were kept free from sexual abuse out of five sample residents. Specifically, the facility failed to: -Protect Resident #4 from sexual abuse by Resident #3; and, -Protect Resident #2 from sexual abuse by Resident #3. Findings include: .. *** CITATION TEXT NOT FOUND *** A complaint survey, prompted by #CO40253, Incident #40153 and Incident #40317 was conducted on 6/23/25. One deficiency was 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

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. The deficient practice affected all smoke c.. Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. The deficient practice affected 4 o.. Based on observation and staff interviews during the record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101.The deficient practice affected all smoke.. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain hazard areas in accordance with NFPA 101, 99, and 58. The deficient practice affected all smoke compartments.1. T.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19.The deficient practice affected all sm.. Based on observation and staff interviews, it was determined that the facility failed to maintain wiring in accordance with NFPA 99 and NFPA 70. The deficient practice affected 4 of 6 smoke compartments1.331 broken outlet cover beh.. Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. The deficient practice affected all smoke compartments.No Semi-Annual Hood Inspection repor.. Based on observations and a review of records, it was determined that the facility did not maintain fire extinguishers in accordance with NFPA 10. The deficient practice affected 1 of 6 smoke compartments1. K class hydro due to no si.. Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. The deficient practice affected 1 of 6 smoke compartments1. Rm 348 has 2 concentrators1.. Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). The deficient practice affected all smoke compartment.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6. The deficient practice affected all smoke compartments.1. Missing January and Febru.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This s.. Through observation during the survey, it was determined that the facility failed to meet the rubbish chutes, incinerators, and laundry chute requirements in accordance with NFPA 101. The deficient practice affected 3 of 6 sm..

A recertification survey with complaint #CO36740 and Incident #38939, Incident #38982 and Incident #39940 was completed on 1/13/25 to 1/16/25. Eleven deficiencies were cited. An Emergency Preparedness survey was conducted from 1/13/25 to 1/16/25. No deficiencies were cited. Based on observations, record review and interviews the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the residents' status based on the criteria outlined in the resident assessment instru.. Based on observations, record review and interviews, the facility failed to ensure care for residents in a manager and in an environment that maintains or enhances each resident' s dignity and respect, in full recognition of his or her indi.. Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in five of five nourishment refrigerators.Specifically, the facility failed to ensure saf.. Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs in one of five dining rooms.Specifically, the facility failed to en.. Based on observations, record review and interviews, the facility failed to ensure that a consent and a safety bed rail evaluation was in place for one (#151) of five residents with bed rails out of 53 residents.Specifically, the facility fail.. Based on observations, record review and interviews, the facility failed to ensure two (#45 and and #95) of five residents who required respiratory care received the care consistent with professional standards of practice out of 53.. Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and c.. Based on observations, record review, and interviews, the facility failed to honor a resident' s choice for laundry services, for one (#113) out of 33 residents reviewed out of 53 sample residents. Specifically, the facility failed to en.. Based on record review and interviews, the facility failed to maintain accurately documented medical records for one (#114) of four residents out of 53 sample residents.Specifically, the facility failed to ensure Resident #114' s wound or.. Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth,.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Nam..