Adara Living

In the surveyor’s words

From the most serious findings on record at Adara Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 8, 2023

  Based 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. […]

• Actual harm, patternF550Aug 8, 2023

  Based 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. Findings include: I. […]

• Actual harm, patternF867Aug 8, 2023

  Based 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. Findings include: I. […]

• Actual harm, isolatedF760Dec 8, 2025

  Based 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. […]

• Actual harm, isolatedF689May 30, 2023

  Based on record review and interviews, the facility failed to ensure one (#4) of six residents reviewed for accidents out of six sample residents remained as free from accident hazards as possible. Resident #4 sustained head trauma (concussion) and extensive bruising to her legs, face and scalp when she was transferred by staff with a Hoyer (mechanical) lift. The facility staff did not assess the resident after the incident. Right after the incident, the resident was sent to her scheduled appointment with a cardiologist. The resident developed a headache, blurred vision and nausea where she was sent to the emergency room (ER) by a cardiologist and diagnosed with a concussion and scalp hematoma. Findings include: I. […]