Adara Living

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#19 and #18) of nine residents reviewed for medication management were free from significant medication errors out of 22 sample residents. Resident #19 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, respiratory failure, peripheral vascular disease, and thrombocytopenia (a deficiency of platelets in the blood). On 8/21/25 at 6:38 p.m. Resident #19 was sent out to the emergency department from the facility due to an acute change of condition. Resident #19 was found to have low blood pressure, a decrease in responsiveness, an increase in lethargy and was unable to follow the nursing staff's commands. While at the hospital, it was documented Resident #19 suffered an accidental medication overdose after she was given another resident's medications. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to prevent an accident for one (#12) of six residents out of 22 sample residents. Specifically, the facility failed to ensure certified nurse aide (CNA) #4 transferred Resident #12 appropriately, which resulted in a fall for the resident.

Inspectors wroteBased 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.

Inspectors wroteBased 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 safe and appropriate storage of food items in the nourishment refrigerators.

Inspectors wroteBased on record review and interviews, the facility failed to ensure six (#98, #16, #127, #106, #116 and #67) of 33 residents reviewed for abuse out of 53 sample residents were free from abuse. Specifically, the facility failed to: -Prevent resident to resident physical abuse between Resident #98 and Resident #16, who had a history of physically and verbally aggressive behaviors towards other residents and staff; -Protect Resident #67 from physical abuse from Resident #127; -Protect Resident #106 from physical abuse from Resident #127; and, -Prevent a resident to resident physical abuse altercation between Resident #116 and Resident #127.

Inspectors wroteBased 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 consumption on two of three floors. Specifically, the facility failed to ensure safe and appropriate storage of food items in resident's personal refrigerators.

Inspectors wroteBased 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, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident dementia abuse prevention. Specifically the facility failed to: -Provide annual resident abuse prevention training/education to 46 out of 212 staff members; and, -Provide annual dementia management education/training for 42 out of 212 staff members.

Inspectors wroteBased 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 individuality for one of four residents out of 53 sample residents reviewed for respect and dignity. Specifically, the facility failed to ensure a resident was provided privacy while using the restroom.

Inspectors wroteBased 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 ensure Resident #113's laundry was consistently saved and stored for his wife to launder due to his multiple allergies.

Inspectors wroteBased 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 instrument (RAI) for one (#83) of 18 residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #83's MDS accurately indicated the resident was receiving hospice services.

Inspectors wroteBased 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 sample residents. Specifically, the facility failed to: -Implement a routine cleaning schedule for the care of Resident #45's continuous positive airway pressure (CPAP) machine; -Ensure a care plan was in place and implemented for Resident #45's CPAP machine to include route of administration, oxygen supplementation, storage, cleaning and machine settings; and, -Ensure a functional continuous positive airway pressure (CPAP) machine was available, cleansed, stored, and maintained for Resident #45 and Resident #95.

Inspectors wroteBased 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 failed to: -Ensure a signed consent was obtained from Resident #151 or the resident's representative prior to the initiation of side rails; -Ensure a physical therapy or occupational therapy (PT/OT) safety evaluation was conducted for Resident #151 prior to the use of half bed rails on a new bed; -Ensure the least restrictive alternatives were tried and documented prior to the use of half rails; and, -Ensure a physician's order was obtained for Resident #151 prior to the use of bed rails.

Inspectors wroteBased 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 ensure residents who were prescribed mechanically altered diets had food prepared according to the resident's diet orders of mechanical soft as indicated on their meal tray cards.

Inspectors wroteBased 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 orders and treatment records were accurate.

Inspectors wroteBased on interviews, observation and record review, the facility failed to ensure one (#156) out of 71 sample residents were free from significant medication errors. Specifically, the facility failed ensure Resident #156, who was recently hospitalized for an acute embolism and was a high risk for deep vein thrombosis (DVT), was administered anticoagulant medication (Eliquis) as ordered upon discharge from the hospital. The facility failed to ensure the transcription of medications from the hospital records was accurate, which resulted in a failure to provide anticoagulant medication, which led to the resident developing a pulmonary embolism resulting in cardiac arrest. [...]

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure residents had the right to a dignified experience. The facility failed to ensure Resident #113 did not experience feeling humiliation during an episode of incontinence. The facility failed to treat Resident #127 with respect and dignity when the staff used foul language toward him and told him to clean his own bathroom. Additionally, the facility failed to provide a culture and environment that promoted residents being treated with dignity and respect.

Inspectors wroteBased on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to significant medications errors that rose to the level of immediate jeopardy and residents were provided respect and dignity by staff that caused a pattern of psychosocial harm.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required per their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to consistently provide adequate nursing staff given the acuity and diagnoses of the facility's population, resident census, and the residents' daily need for care and services. Cross-reference citations: -F677 for the failure to provide timely incontinence care and reposition to residents; -F686 for the failure to provide repositioning for residents with pressure injuries; -F689 for the failure to ensure two staff were utilized when transferring residents with mechanical lifts; [...]

Inspectors wroteBased on observations and interviews, the facility failed to prepare and serve food in a sanitary manner. Specifically, the facility failed to have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had safe, clean, comfortable and homelike environments in multiple areas of the facility. Specifically, the facility failed to ensure resident rooms and facility hallways.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure seven (#19, #69, #90, #92, #25, #98 and #75) residents were provided prompt efforts by the facility to follow up on grievances out of 71 sample residents. Specifically, the facility failed to ensure grievances were followed up timely with a resolution in regards to missing property.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to consistently provide activities of daily living (ADL) support for three (#27, #98 and #106) of six dependent residents reviewed for ADL care out of 71 sample residents. Specifically, the facility failed to: -Provide repositioning adjustments for Resident #27 and Resident #98 who were unable to reposition themselves; and, -Provide timely incontinence care for Resident #27 and Resident #106. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and services

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#78, #89 and #127) of five out of 71 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure Resident #78 did not receive another resident's medications; -Ensure Resident #89 was transferred with a mechanical lift according to professional standards of practice; and, -Ensure cleaning chemicals were not left in Resident #127's room unsecured.

Inspectors wroteBased on record review and interview the facility failed to ensure certified nurse aides (CNAs) received 12 hours of training per year for seven (CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24, and CNA #25) out of 49 CNAs. Specifically, the facility failed to provide 12 hour training for CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24 and CNA #25.

Inspectors wroteBased on observations and interviews the facility failed to ensure three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted professional standards. Specifically, the facility failed to ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator.

Inspectors wroteBased on observations, record review and interviews; the facility failed to provide food that accommodated resident preferences for four (#13, #78, #79 and #86) of four residents out of 71 sample residents. Specifically the facility failed to offer food choices according to resident preferences for Residents #13, #78, #79 and #86.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure: -Housekeeping staff engaged in appropriate infection control practices when cleaning a resident room; -Residents were provided with proper hand hygiene prior to meals; -Proper hand hygiene was conducted during medication pass; and, -Shared equipment was consistently sanitized between resident uses.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents.

Inspectors wroteBased on record review and interviews the facility failed to keep two residents (#108 and #133) free from resident to resident physical abuse of two residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure there was an effective plan to monitor, or provide increased oversight and effective interventions to protect, Residents #108 and #133 from Resident #409's behavior. Resident #409 physically abused two residents on 7/9/23.

Inspectors wroteBased on interviews and record review, the facility failed to provide written information regarding the facility's bed-hold policy to a resident's representative for one (#409) resident reviewed for discharge out of 71 sample residents. Specifically, the the facility failed to provide Resident #409's representative with a written notice of the bed hold policy when he was transferred to the hospital.

Inspectors wroteBased on interviews and record review, the facility failed to allow a resident to return to the facility after going to the hospital for one (#409) of one resident reviewed for discharge out of 71 sample residents. Specifically, the facility failed to assess Resident #409 when he went to the hospital to be stabilized to return to the facility.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure two of three residents (#41 and #136) reviewed for activities of daily living (ADLs) received the necessary care and services to maintain their abilities in ADLs out of 71 sample residents. Specifically, the facility failed to provide language communication tools in order for Resident #41 and #136 to effectively communicate their needs, requests, and opinions, as well as to participate in social conversation.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#69) of two residents out of 71 sample residents. Specifically, the facility failed to offer and provide activity programs for Resident #69 to meet her activity needs.

Inspectors wroteBased on interviews, observation and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#7) out of 71 sample residents. Specifically, the facility failed to ensure Resident #7, who was diagnosed with diabetes, had her fingernails cut by a licensed nurse. Resident #7 sustained a laceration on her finger when the certified nurse aide (CNA) cut her nails.

Inspectors wroteBased on record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for two (#23 and #85) of two residents in a sample of 71 residents. Specifically, the facility failed to implement or plan interventions to reduce pressure injury risk factors for Resident #23 and #85, both of whom had been identified at high risk for pressure injuries. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and services

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#130 and #92) of three out of 71 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically, the facility failed to: -Ensure Resident #130 received assistance to meet her nutrition and hydration needs; and, -Ensure Resident #92 received sufficient hydration.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#108) resident who required respiratory care received the care consistent with professional standards of practice out of 71 sample residents. Specifically, the facility failed to ensure a portable oxygen concentrator was in working condition for Resident #108.

Inspectors wroteBased on record review and interviews the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#143) resident reviewed for antibiotic stewardship out of 71 sample residents. Specifically, the facility failed to thoroughly assess and document clinical signs and symptoms of an infection to ensure the criteria of the infection was met prior to the administration of an antibiotic for Residents #143.

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure over-the-counter medications were secured for 1 (Resident #115) of 8 sampled residents who resided on the third floor.