Adira Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 14, 2022

  This Citation pertains to Intake Numbers MI 918 and MI 949 Based upon observation, interview and record review the facility is placed in Immediate Jeopardy for its failure to ensure appropriate interventions, assessment and monitoring were in place to prevent a resident-to-resident assault, resulting in Resident #502 strangling Resident #501. On 2/3/22, at approximately 7:00 PM, Resident #502 walked into Resident #501's room, unprovoked, grabbed his shirt with one hand and strangled Resident #501 with his other hand. Resident #502 proceeded to drag Resident #501 into the hallway where he continued to strangle him. Nurse A separated the residents and Resident #502 punched Nurse A with a closed fist in the face and neck. […]

• Immediate jeopardy, isolatedF684Dec 17, 2021

  This Citation pertains to Intake Number MI 851. Based on observation, interview, and record review the facility failed to replenish Automated External Defibrillator (AED) pads for their one AED device in the facility, resulting in failure to utilize the AED when Resident #701 was found unresponsive by Licensed Practical Nurse (LPN) A, on [DATE] at 3:30 AM. LPN A immediately began to perform Cardiopulmonary Resuscitation (CPR) on the resident. The facility's crash cart was brought into the resident's room and, as the nurses attempted to attach the AED, it was found there were no AED pads. LPN B searched both crash carts for AED pads but was not able to locate any. […]

• Actual harm, isolatedF697Jan 22, 2026

  Based on interview and record review the facility failed to initiate timely pain interventions for two residents (Resident #13 & Resident #81) of two residents reviewed for pain, resulting in both Resident #13 and Resident #81 experiencing documented increased pain after falls (which resulted in femur fractures requiring surgical repair), without any pharmacological or non-pharmacological interventions provided and a12 + hour delay in transferring both residents to the hospital for proper evaluation and treatment.Findings Include:Resident #13:Review was conducted of Resident #13's chart and it revealed she admitted to the facility on [DATE] with diagnoses that included, Alzheimer's Disease, Diabetes, Asthma, Dementia, Heart Failure and Hypertension. […]

• Actual harm, isolatedF686Sep 16, 2025

  This citation pertains to Intake Number 2607357.Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for one resident (Resident #1) of three residents reviewed for skin alterations, resulting in Resident #1 developing three facility-acquired pressures ulcers- one Stage 3 pressure ulcer ( full- thickness skin loss with exposure of the subcutaneous tissue layer beneath) to his coccyx: unstageable wound (full- thickness loss where the depth of the wound is obscured by necrotic tissue or eschar) to his left heel and a deep tissue injury (pressure related injury to subcutaneous tissues that appears as deep bruise under intact skin) to his left lateral malleolus and inconsistencies in classification of the wounds. […]

• Actual harm, isolatedF686Oct 31, 2024

  This Citation Pertains to Intake Numbers MI00147625, MI00147548, and MI00147423 Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure pressure ulcer prevention and management for five residents (#5, #56, #58, #60, and #76) of eight residents reviewed. This deficient practice resulted in a lack of implementation of meaningful, appropriate, and planned interventions for pressure ulcer prevention, multiple residents developing pressure ulcers, unnecessary pain, and the likelihood for a decline in overall health status. Findings include: Resident #56: On 10/28/24 at 11:10 AM, Resident #56's room door was observed to be closed. […]