Adira At Riverside Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Adira At Riverside Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 17, 2025

  Based on record review and interview conducted during the abbreviated survey (2581942), the facility failed to ensure all residents were free of accident hazards and that each resident received assistance to prevent falls for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, Resident #1 sustained a head injury after a fall from their bed on 08/05/2025. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.Findings include: The policy titled 'Fall Prevention Program' issued 03/28/2021 and reviewed 05/30/2025 documented all residents, by virtue of age, illness/injury and placement, are considered to be at risk for falls. […]

• Actual harm, isolatedF686Aug 30, 2024

  Based on interview, observation and record review during a Recertification Survey conducted from 8/26/2024 through 8/30/2024, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and to prevent the development of pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. This was evident for 1 of 4 residents reviewed for pressure ulcers (Resident #24). Specifically, Resident #24 was assessed as high risk for pressure ulcers and was identified to have left heel redness on 08/24/2024. The resident's care plan and interventions were not promptly updated and implemented to prevent further deterioration of the left heel skin integrity. […]

• No harm, potential for more than minimal, patternF684Apr 14, 2026

  Based on observations, interviews, and record review conducted during the abbreviated survey, the facility did not ensure residents received quality care for two (2) (Residents #1 and #6) of five (5) residents reviewed for pressure ulcers. Specifically, 1) Resident #6 was ordered to receive wound treatment more frequently than recommended by the wound care specialist, 2) wound care specialist findings and recommendations for Resident #1 were not accurately transcribed and signs of worsening infection were not thoroughly reviewed and addressed.The findings are:1) Resident #6 had diagnoses of chronic respiratory failure with ventilator dependence and cerebral infarction.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #6 was severely cognitively impaired and totally… […]

• No harm, potential for more than minimal, patternF686Apr 14, 2026

  Based on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure residents with pressure ulcers received treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing in two (Residents #1 and #3) of five residents reviewed for pressure ulcers. Specifically, there was no documented evidence Resident #1's treatment plan was revised to address stagnant wound progress and serosanguinous ulcer drainage for multiple weeks, and 2) Resident #3 was admitted to the facility at risk for skin breakdown and there was no documented evidence they received devices and repositioning to prevent the development of six new pressure injuries.The findings are:The… […]

• No harm, potential for more than minimal, patternF711Apr 14, 2026

  Based on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for two (Residents #6 and #1) of four ventilator-dependent residents sampled. Specifically, 1) discrepancies in the wound specialist's and the attending physician's ordered treatments were not addressed during physician visits, and 2) there was no evidence the attending physician reviewed labs reporting increasingly abnormal values and wound notes reporting stagnant, unhealing wounds with ongoing drainage.The findings are:1) Resident #6 had diagnoses of chronic respiratory failure with ventilator dependence and cerebral infarction.Resident #6's facesheet… […]