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Deficiency Records for Adira Nursing and Rehab
A list of the most recent deficiencies for Adira Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Adira Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2023-12-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-30 | 2023-12-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-30 | 2023-12-28 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-30 | 2023-12-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2023-12-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-30 | 2023-12-28 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-30 | 2023-12-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-30 | 2023-12-28 | N |
| Post nurse staffing information every day. | Health | 2023-11-30 | 2023-12-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-30 | 2023-12-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-30 | 2023-12-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-30 | 2023-12-28 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-11-30 | 2023-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2023-12-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-30 | 2023-12-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-30 | 2023-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-30 | 2023-12-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-30 | 2023-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-30 | 2023-12-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-30 | 2023-12-28 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-28 | 2023-12-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-07 | 2023-07-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-07 | 2023-07-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-29 | 2022-12-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-29 | 2022-12-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-29 | 2022-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-29 | 2022-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-28 | 2022-08-16 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-11 | 2022-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-25 | 2022-06-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-12 | 2022-06-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-12 | 2022-06-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-12 | 2022-06-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-12 | 2022-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-12 | 2022-06-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-12 | 2022-06-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-12 | 2022-06-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-12 | 2022-06-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-05-12 | 2022-06-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-12 | 2022-06-16 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-05-12 | 2022-06-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-12 | 2022-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-06-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-12 | 2022-06-16 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-05-12 | 2022-06-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-11 | 2022-06-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-11 | 2022-06-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-11 | 2022-06-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-11 | 2022-06-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-11 | 2022-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-11 | 2022-06-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-14 | 2022-04-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-03-14 | 2022-04-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-30 | 2022-04-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-17 | 2022-01-14 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-28 | 2020-04-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-02-28 | 2020-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-28 | 2020-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-28 | 2020-04-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-28 | 2020-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-28 | 2020-04-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-28 | 2020-04-01 | N |
| 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. | Health | 2020-02-28 | 2020-04-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-02-28 | 2020-04-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-28 | 2020-04-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-28 | 2020-04-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-28 | 2020-04-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-28 | 2020-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-28 | 2020-04-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-28 | 2020-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-28 | 2020-04-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-28 | 2020-04-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-26 | 2020-04-01 | N |
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