Adira Medical Resort

In the surveyor’s words

From the most serious findings on record at Adira Medical Resort, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 23, 2025

  Based on record review, observations, and interviews, the facility failed to assess a resident upon readmission for the risk of elopement and failed to identify the need for supervision related to wandering tendencies displayed by a resident for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for elopement. The deficient practice resulted in an Immediate Jeopardy for Resident #1 on 06/10/2025 when Resident #1 walked out of the facility's locked front door with S1Medical Director and was left unattended on the facility's front porch. Resident #1 walked along a busy 4 lane road without supervision and entered a dental office business approximately 37 feet from the facility's parking lot. Resident #1 was last observed in the facility at approximately 9:00 a.m. […]

• Immediate jeopardy, isolatedF835Jun 23, 2025

  Based on record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 3 (#1, #2, #3) sampled residents reviewed for elopement. S3Director of Nursing (DON) failed to ensure the nursing staff conducted a risk for elopement assessment for Resident #1 at the time of readmission to the facility and failed to implement elopement precautions. The deficient practice resulted in an Immediate Jeopardy for Resident #1 on 06/10/2025 when Resident #1 walked out of the facility's locked front door with S1Medical Director and was left unattended on the facility's front porch. […]

• No harm, potential for more than minimal, widespreadF578Oct 17, 2024

  34708 Based on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure: 1. Resident's medical records accurately reflected the residents' wishes for emergency basic life support for 8 (#1, #15, #9, #76, #77, #126, #127, #175 ) residents; 2. Failed to document residents and/or resident's representative were given information on Advanced Directives on admission for 12 (#9, #76, #77, #126, #127, #175, #4, #11, #12, #20, #75, #125) residents, of 19 (#9, #77, #11, #75, #12, #76, #125, #126, #1, #127, #4, #20, #15, #175, #2, #8, #22, #24, and #18) residents reviewed for Advanced Directives. […]

• No harm, potential for more than minimal, patternF656Apr 1, 2026

  Based on record reviews and interview the facility failed to ensure physician orders were followed for 3 (#1, #2, and #5) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for wounds. The facility failed to ensure evidence that wound care was conducted as ordered. Findings:Review of undated policy titled Wound Treatment Management revealed, in part:Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. […]

• No harm, potential for more than minimal, patternF641Jun 23, 2025

  Based on record review and interviews, the facility failed to assess a resident for the risk of elopement and failed to ensure an assessment accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement, impaired cognition and/or a diagnosis which may increase the risk of elopement by failing to: 1. Ensure a nursing assessment and elopement risk assessment were completed for Resident #1 at the time of readmission on [DATE]. 2. Ensure Resident #1's behavioral section on Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/31/2025 was completed accurately. […]