Inspection Reports for
Adara Living
12975 SHERIDAN BLVD, BROOMFIELD, CO, 80020-1477
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
213% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 8, 2025
Visit Reason
The inspection was conducted due to complaints and incidents involving resident safety, specifically related to a resident fall and significant medication errors affecting multiple residents.
Complaint Details
The investigation was complaint-driven, focusing on a fall incident involving Resident #12 and medication errors involving Residents #18 and #19. The medication errors were substantiated, resulting in hospitalizations and changes in resident condition.
Findings
The facility failed to prevent a fall for one resident due to improper transfer by staff and failed to ensure correct medication administration for two residents, resulting in actual harm and hospitalizations. The facility implemented corrective actions including staff education, updated policies, and monitoring.
Deficiencies (2)
F 0689: The facility failed to prevent a fall for Resident #12 when a certified nurse aide transferred the resident without proper mechanical lift assistance, resulting in a fall and a 7 cm skin tear with bleeding.
F 0760: The facility failed to ensure two residents (#18 and #19) did not receive another resident's medications, causing significant medication errors that led to hospital transfer and adverse health effects.
Report Facts
Residents reviewed for medication management: 9
Sample residents: 22
Skin tear size: 7
Narcan dosage: 2
Medication administration observations: 2
New nurses hired: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Named in fall incident involving improper transfer of Resident #12. | |
| RN #2 | Registered Nurse | Interviewed regarding Resident #12 fall incident and communication about care plans. |
| Director of Nursing (DON) | Director of Nursing | Interviewed about transfer procedures, medication administration policies, and investigations. |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Provided facility policies, interviewed about education and corrective actions after incidents. |
| RN #1 | Registered Nurse | Interviewed about medication administration process and training. |
| LPN #1 | Licensed Practical Nurse | Agency nurse interviewed about medication administration procedures. |
| RN #3 | Registered Nurse | Involved in medication error incident with Resident #18 and Resident #16. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 23, 2025
Visit Reason
The inspection was conducted to investigate complaints of sexual and physical abuse involving residents at the facility.
Complaint Details
The complaint investigation substantiated sexual abuse by Resident #3 towards Residents #4 and #2. Resident #3 admitted to the abuse and was placed on one-to-one caregiver monitoring indefinitely.
Findings
The facility substantiated incidents of sexual abuse by Resident #3 towards Residents #4 and #2. Resident #3 was placed on one-to-one caregiver monitoring following the incidents. The facility had policies to prevent abuse but failed to prevent these occurrences.
Deficiencies (2)
F 0600: The facility failed to protect Resident #4 from sexual abuse by Resident #3. Resident #3 grabbed Resident #4's shirt and touched her breast without consent.
F 0600: The facility failed to protect Resident #2 from sexual abuse by Resident #3. Resident #3 grabbed Resident #2's breast twice during an interaction.
Report Facts
Residents affected: 2
Dates of incidents: Sexual abuse incidents occurred on 5/2/25 and 5/20/25.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding incidents and witnessed Resident #3's inappropriate behavior. |
| NHA | Nursing Home Administrator | Provided facility policy and conducted investigations related to abuse incidents. |
| DON | Director of Nursing | Interviewed staff and residents during the abuse investigations. |
| LPN #1 | Licensed Practical Nurse | Interviewed about incidents and staff assignments following abuse events. |
Inspection Report
Routine
Deficiencies: 11
Date: Jan 16, 2025
Visit Reason
Routine state inspection survey of Adara Living nursing home to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, honoring resident choices, abuse prevention, respiratory care, food safety, bed rail use, medical record accuracy, and staff training on abuse and dementia care.
Deficiencies (11)
F 0550: The facility failed to ensure a resident was provided privacy while using the restroom, exposing the resident to the hallway with doors left open.
F 0561: The facility failed to honor a resident's choice for laundry services, resulting in inconsistent handling of laundry despite allergies.
F 0600: The facility failed to prevent multiple incidents of resident-to-resident physical abuse involving several residents with aggressive behaviors.
F 0641: The facility failed to ensure the minimum data set assessment accurately reflected a resident's hospice status, coding hospice care in error.
F 0695: The facility failed to ensure two residents' CPAP machines were properly cleaned, maintained, and functional according to professional standards and physician orders.
F 0700: The facility failed to obtain signed consent, conduct safety evaluations, try least restrictive alternatives, and obtain physician orders prior to use of bed rails for a resident.
F 0805: The facility failed to ensure residents on mechanically altered diets received food prepared according to diet orders, serving potatoes with skins contrary to diet manual restrictions.
F 0812: The facility failed to ensure safe and appropriate storage of food items in nourishment refrigerators, including unlabeled items, expired supplements, and unsanitary conditions.
F 0813: The facility failed to implement policy for safe storage and handling of foods brought by visitors in residents' personal refrigerators, including lack of labeling and temperature monitoring.
F 0842: The facility failed to maintain accurate medical records for a resident's wound care, including incorrect wound location and delayed update of treatment orders.
F 0943: The facility failed to provide annual abuse prevention and dementia management training to all staff, with 42-46 staff members lacking required education.
Report Facts
Staff lacking annual abuse training: 46
Staff lacking annual dementia training: 42
Sample residents reviewed: 53
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to multiple allegations of resident-to-resident physical abuse incidents involving several residents at the facility.
Complaint Details
The complaint investigation involved physical abuse allegations between residents #98 and #16 on 1/6/25, #67 and #127 on 9/23/24, #106 and #127 on 12/20/24, and #116 and #127 on 1/3/25. Some abuse was substantiated as witnessed altercations, but some were unsubstantiated due to lack of intent or injury.
Findings
The facility failed to prevent and protect residents from physical abuse by other residents in multiple incidents. Investigations found physical altercations between residents with some injuries and behavioral issues contributing to the events. Although abuse was witnessed, some allegations were unsubstantiated due to lack of intent or injury.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse by other residents, as evidenced by multiple resident-to-resident physical altercations.
Report Facts
Residents reviewed for abuse: 33
Sample residents: 53
BIMS scores: 3
BIMS scores: 6
BIMS scores: 10
Laceration size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nurse Aide | Interviewed regarding behaviors of Residents #98 and #16 and their interactions. |
| LPN #3 | Licensed Practical Nurse | Interviewed about Resident #98's behaviors and monitoring. |
| UM #2 | Unit Manager | Interviewed about Resident #98 and Resident #16 behavior history and interventions. |
| DON | Director of Nursing | Interviewed regarding Resident #98 and Resident #16 behavior management and investigations. |
| NHA | Nursing Home Administrator | Interviewed jointly with DON about resident behaviors and investigations. |
Inspection Report
Census: 158
Deficiencies: 23
Date: Aug 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care, safety, infection control, staffing, medication administration, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity and respect, inadequate staffing leading to unmet care needs, medication errors including a fatal anticoagulant omission, failure to provide adequate nutrition and hydration, improper infection control practices, and failure to maintain a safe environment.
Deficiencies (23)
F0550: The facility failed to ensure residents were treated with dignity and respect, including incidents of humiliation and use of foul language by staff.
F0574: The facility failed to provide residents with notices in accessible formats and failed to include the State Survey Agency's email for complaints.
F0584: The facility failed to maintain safe, clean, and homelike environments, including pest infestations and damaged fixtures.
F0585: The facility failed to promptly and effectively follow up on resident grievances related to missing property.
F0600: The facility failed to protect residents from physical abuse by another resident and failed to provide effective interventions for the assailant.
F0625: The facility failed to provide written notice of bed-hold policy to Resident #409's representative upon hospital transfer.
F0626: The facility failed to permit Resident #409 to return after hospitalization and failed to reassess and communicate regarding readmission.
F0676: The facility failed to provide effective communication tools for residents with language barriers, limiting their ability to express needs and participate socially.
F0677: The facility failed to provide timely incontinence care and repositioning for dependent residents.
F0684: The facility failed to ensure appropriate nail care for a diabetic resident, resulting in a laceration.
F0686: The facility failed to provide appropriate pressure ulcer care and prevention for residents at high risk.
F0689: The facility failed to ensure mechanical lifts were used with two staff as required and failed to secure controlled medications in refrigerators.
F0692: The facility failed to provide adequate nutrition and hydration assistance to residents, resulting in weight loss and dehydration.
F0695: The facility failed to ensure a portable oxygen concentrator was in working condition for a resident requiring oxygen therapy.
F0725: The facility failed to provide sufficient nursing staff to meet residents' care needs given acuity and census.
F0730: The facility failed to ensure certified nurse aides received required annual training hours.
F0760: The facility failed to ensure accurate transcription and administration of anticoagulant medication for a resident, resulting in pulmonary embolism and death.
F0761: The facility failed to ensure controlled medications in refrigerators were secured in permanently affixed locked compartments.
F0806: The facility failed to provide food that accommodated resident preferences for multiple residents.
F0812: The facility failed to monitor internal dishwasher temperature to ensure proper sanitization.
F0867: The facility failed to implement an effective quality assurance program to identify and address significant medication errors and psychosocial harm.
F0880: The facility failed to maintain infection prevention and control practices including housekeeping, hand hygiene, medication pass hygiene, and equipment sanitation.
F0881: The facility failed to implement an antibiotic stewardship program ensuring appropriate assessment and documentation prior to antibiotic administration.
Report Facts
Resident census: 158
Weight loss: 5.26
Weight loss: 3.1
Fluid intake: 340
Fluid intake: 1920
Medication administration: 0
Medication administration: 12
Medication administration: 7
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Aug 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error involving Resident #156, who did not receive prescribed anticoagulant therapy after hospital discharge.
Complaint Details
The complaint investigation substantiated that Resident #156 was not administered anticoagulant medication as ordered upon discharge, resulting in a pulmonary embolism and death. Immediate jeopardy was identified and removed after the facility submitted and implemented a corrective plan.
Findings
The facility failed to accurately transcribe hospital discharge medication orders for Resident #156, resulting in failure to administer anticoagulant therapy. This led to the resident developing a pulmonary embolism, cardiac arrest, and death. Immediate jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (1)
F0760: The facility failed to ensure residents were free from significant medication errors. Resident #156 did not receive prescribed anticoagulant therapy after hospital discharge, leading to pulmonary embolism and death.
Report Facts
Sample residents reviewed: 71
Residents affected: 1
Date survey completed: Aug 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered nurse #3 | Registered Nurse | Interviewed regarding medication transcription and anticoagulant therapy |
| Director of Nursing | Director of Nursing | Interviewed regarding medication review process and Resident #156's care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #4 sustained injuries during a transfer using a Hoyer lift.
Complaint Details
Resident #4 sustained a concussion and extensive bruising during a transfer with a Hoyer lift. The resident was sent to a cardiologist appointment immediately after the incident without assessment by facility staff. The resident later went to the ER and was diagnosed with a concussion and scalp hematoma. The facility's investigation was inconclusive, and neurological checks were delayed nearly 24 hours after the incident.
Findings
The facility failed to ensure Resident #4 was free from accident hazards during transfer, resulting in head trauma and bruising. The resident was not assessed immediately after the incident, and the investigation was inconclusive regarding the cause of the lift tilting. The facility did not monitor bruises or provide timely neurological checks.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in actual harm to Resident #4 during a Hoyer lift transfer.
Report Facts
Date of incident: May 23, 2023
Date of survey: May 30, 2023
Work order date: May 24, 2023
Pain scale rating: 8
Pain scale rating: 9
Bruise size: 4
Bruise size: 1
Medication dosage: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Involved in documentation and care related to the incident with Resident #4 |
| UM #1 | Unit Manager | Interviewed regarding incident and investigation of Resident #4 |
| ADON | Assistant Director of Nursing | Provided incident report and participated in investigation |
| MTD | Maintenance Director | Inspected Hoyer lifts after incident |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 28, 2023
Visit Reason
The inspection was conducted to investigate complaints related to grievances, discharge notices, return from hospitalization, medication administration, incontinence care, and infection control at the facility.
Complaint Details
The complaint investigation included grievances about incontinence care, failure to provide proper discharge notices and appeal rights, failure to allow a resident to return after hospitalization, medication administration errors, and infection control lapses.
Findings
The facility failed to promptly resolve a grievance regarding incontinence care for Resident #2, failed to provide proper discharge notices and allow Resident #6 to return after hospitalization, failed to administer medications properly to Residents #9 and #10, failed to provide incontinence care after meals to Resident #2, and failed to maintain infection control by not sanitizing a water pitcher dropped on the floor.
Deficiencies (7)
F585: The facility failed to ensure Resident #2's grievance regarding incontinence care was resolved timely.
F623: The facility failed to provide Resident #6 and responsible parties with appropriate discharge notice including appeal rights.
F626: The facility failed to allow Resident #6 to return after hospitalization despite being medically stable and cleared.
F658: The facility failed to ensure medications were not left at the bedside in a resident's room.
F677: The facility failed to provide incontinence care to Resident #2 after the meal.
F684: The facility failed to administer morning medications to Resident #10 and afternoon insulin to Resident #9 as ordered.
F880: The facility failed to clean and sanitize a water pitcher dropped on the floor before returning it to Resident #11.
Report Facts
Sample residents reviewed: 12
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
BIMS score: 3
BIMS score: 10
BIMS score: 0
BIMS score: 5
Blood sugar: 366
Insulin dose: 4
Insulin dose: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided facility policies, interviewed regarding grievances, medication administration, and infection control | |
| Unit Manager #1 | Interviewed regarding grievance process and infection control | |
| Unit Manager #2 | Interviewed regarding medication administration and crushing orders | |
| Licensed Practical Nurse #3 | Observed administering medications and insulin, involved in medication administration deficiencies | |
| Social Services Director | Interviewed regarding grievance and discharge processes | |
| Nursing Home Administrator | Interviewed regarding grievance and discharge decisions | |
| Primary Care Physician #1 | Interviewed regarding insulin administration timing and importance | |
| Pharmacy Consultant | Interviewed regarding medication administration practices | |
| Nurse Practitioner #1 | Interviewed regarding medication crushing and timing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 19, 2022
Visit Reason
The inspection was conducted to investigate a complaint regarding unsecured over-the-counter medications found in a resident's room at the nursing home.
Complaint Details
The complaint investigation found that Resident #115 had unsecured medications in their room without physician orders or self-administration assessment. The resident failed the self-administration test and medications were removed by staff. The complaint was substantiated with findings.
Findings
The facility failed to ensure that over-the-counter medications were secured for Resident #115, who was moderately cognitively impaired and had no physician's order or assessment for self-administration of medications. Medications were found unsecured on the resident's bedside table despite facility policy requiring locked storage and proper assessment.
Deficiencies (1)
F 0689: The facility failed to ensure over-the-counter medications were secured for Resident #115. Medications were found unsecured on the bedside table without physician orders or self-administration assessment.
Report Facts
Residents sampled: 8
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Stated medications should not be in resident rooms | |
| Registered Nurse (RN) Third Floor Unit Manager | Conducted self-administration assessment and removed medications | |
| Certified Nursing Assistant (CNA) #1 | Observed medications in Resident #115's room | |
| Licensed Practical Nurse (LPN) #2 | Reviewed physician's orders and confirmed no order for medications in room | |
| Director of Nursing (DON) | Stated medications were not supposed to be in Resident #115's room | |
| Administrator | Stated expectation for resident assessment before medications left in room |
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