Adira Nursing and Rehabilitation

Inspectors wroteThis citation pertains to Intake Number 2976205. Based on interview and record review the facility to implement a process for receipt of and reconciliation of home medications for one resident (Resident #701) of two residents reviewed for pharmacy services. Findings Include:On [DATE] at 10:00 AM, Complainant K shared his father (Resident #701) admitted to the facility for short term rehabilitation after an extended hospital stay. Upon admission he provided the facility with his father's anti-rejection (immunosuppressant) medications to cover the duration of his stay. He gave the facility the following:Tacrolimus 1 mg (milligram)- 2 bottles (30 capsules in each bottle)Tacrolimus 4 mg - 2 bottles (30 capsules in each bottle)Complainant K started he was supposed to receive 5 mg per day (1 mg tablet and 4 mg tablet). [...]

Inspectors wroteBased 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. Resident #13 required assistance of facility staff for daily care. Further review of her chart yielded the following:Progress Notes: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care of an indwelling catheter for one resident (R2) of one resident reviewed for indwelling catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe narcotic storage, narcotic reconciliation and the discarding of expired medications for two medication carts of three medication carts reviewed, resulting in unreconciled narcotic medications with key exchange and expired medications.

Inspectors wroteThis 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. [...]

Inspectors wroteThis Citation Pertains to Intake# MI00150592. Based on observation, interview and record review, the facility failed to ensure 1). Call light notifications were readily available to staff and 2). Call lights were responded to in a timely manner to meet residents' needs including Resident (#6), from a facility census of 82 residents. Findings Include: On 3/6/2025 at 11:45 AM, Nurse G was asked how the staff knew if there was a call light on and said there was a screen at the nurse's desk that showed which lights were on. The 200 unit had 2 halls, with one shorter and one much longer. The call light screen was not visible from either hall. Nurse G said the staff would need to walk to the nurse's desk to see if a call light was on. The nurse said there were no lights or sounds in the halls to indicate if a resident had their call light on. [...]

Inspectors wroteThis Citation Pertains to Intake# MI00150592 This Citation has 2 DPS's Based on observation, interview and record review the facility failed to ensure appropriate interventions were in place to manage skin breakdown for Resident #2 and pressure ulcer treatment to aid in healing for one resident (Resident #3), of 4 residents reviewed for skin breakdown and pressure ulcers, resulting in Resident #2 developing a large, red, excoriated area on his bilateral buttocks and Resident #3 developing an unstageable pressure ulcer on the left lateral malleolus (ankle). Findings Include: Skin conditions Resident #2 A record review of the face sheet and Minimum Data Set/MDS assessment, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: [...]

Inspectors wroteThis Citation Pertains to Intake: MI00150592 . Based on interview and record review, the facility failed to prevent repeat falls for one resident (Resident #1) of 3 sampled residents, resulting in Resident #1 sustaining unwitnessed repeated falls with inconsistent neurological monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Registered Nurse was on duty for eight consecutive hours a day, seven days a week. Findings Include: On 3/6/2025 at 11:30 AM, posted nurse staffing sheets (a document listing all nurse staff by discipline (RN, LPN or Nurse aide working in the building on each shift- posted per federal guidelines) for the year 2025 was requested. A review of the Daily posted staffing sheets from 1/1/2025- 3/6/2025 identified a blank form, as well as a lack of 8 hour daily Registered Nurse (RN) coverage. There were several days in January 2025 that did not have an RN working for at least 8 consecutive hours: 1/1/2025 (0 RN hours), 1/9/2025 (4 RN hours) and 1/24/2025 (0 RN hours). There were several days in February 2025 that did not have an RN working for at least 8 consecutive hours: [...]

Inspectors wroteResident #58: During initial tour on 10/28/2024, Resident #58 was observed resting in bed laying on her back, with only a pillow under her head. Resident #58 was asked if she had any open wounds on her body and she shared she has a sore on her bottom. On 10/28/2024 at approximately 7:30 AM, a review was completed of Resident #58's medical record and it revealed she initially admitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Pressure Ulcer of Sacral region, muscle wasting and atrophy and Acute Kidney Failure. Further review of Resident #58's records yielded the following: Progress Notes: 7/17/2024 at 15:17: When doing a skin assessment on this resident it was noted she has a new pressure wound to her coccyx .ordered an air mattress for the resident . 7/18/2024 at 12:38: [...]

Inspectors wroteThis Citation Pertains to Intake Numbers MI00147548 and MI00147625. Based on observation, interview and record review, the facility failed to ensure dignified, respectful, and professional care and treatment for 12 residents (# 5, #11, #21, #24, #29, #36, #39, #40, #60, #64, #76, and #81) of 12 residents reviewed and 12 of 12 residents from the confidential Resident Group meeting, resulting in a lack of the provision of care, timely response to care needs, extended wait times for assistance, incontinence, and residents' verbalizations of discourteous staff, feelings of being a burden, frustration, and sadness.

Inspectors wroteThis Citation pertains to Intake Numbers MI00147548 and MI00147625. Based on observation, interview and record review the facility failed to document and provide routine showers and hygiene care for 12 residents (#5, #9, #24, #40, #50, #56, #57, #64, #72, #76, #78, #80) of 12 residents reviewed and 7 of 12 residents from confidential Resident Group meeting, resulting in residents' feelings of embarrassment from poor hygiene, and frustration. Findings Include: During a confidential Resident Council meeting held on 10/29/2024 at 11:30 AM, the twelve residents in attendance were queried regarding the care provided to them at the facility. Seven residents stated they were not consistently receiving their showers. Residents stated they had not received showers in two weeks and were not provided with a reason as to why. They expressed frustration as they felt disregarded. Resident #57: [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure proper labeling of medications in 5 of 5 medication carts, and 2 of 2 treatment carts, 2) Failed to properly secure/lock 2 of 2 treatment carts with medical supplies and prescription creams/ointments, 3) Failed to clean up loose medication tablets and debris, and 4) Failed to ensure proper completion of 2 temperature logs for medication refrigerators, resulting in the opened and undated medications, creams/ointments, with the potential for a resident to received medications/treatments with altered/decreased efficacy and potency, drug diversion or ingestion of unlocked medication/treatment carts, cross contamination and inappropriate temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure appropriate hand hygiene and disposal of soiled linens/waste products, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis. and the likelihood for spread of microorganisms and illness to all 84 facility residents.

Inspectors wroteBased on interview and record review the facility failed to complete advance directives for seven residents (R19, R24, R29, R30, R36, R39, R50) of seven residents reviewed for advance directives, resulting in missing or incomplete advance directive forms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that reviews and revisions of residents' care plans were made to ensure interventions necessary for care and services were provided for 5 residents (#5, #9, #40, #78, #80), resulting in a lack of showers/bathing, weight loss and/or catheter care, consistently resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct and maintain timely activity assessments for eleven residents (#4, #5, #26, #28, #32, #37, #42, #45,#75,#77, #79) of 11 residents reviewed for assessments and ensure that one resident (#4) was able exercise their right to vote of 1 resident reviewed for voting preferences. Findings Include: During Resident Council meeting held on 10/29/2024 at 11:30 AM, Resident #4 shared she would like to vote in the upcoming Presidential election and does not recall this being addressed with her. On 10/29/2024 at 2:35 PM, Activities Director R was queried regarding the process for residents voting in the upcoming election. Director R explained upon admission each resident is asked about their preference regarding voting. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure quality of care to meet residents' needs for diabetic and behavioral care and 2) Failure of facility staff to retrieve medications from the backup source for 11 Residents (#5, #9, #41, #46, #50, #56 #72, #76, #81, #137, #147), resulting in the lack of identification and assessment of changes in condition and delays in treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed provide care and services prevent urinary tract infections for 5 residents (#5, #11, #40, #81, #83), resulting in the potential for recurrent urinary tract infections, and cross contamination with the potential for prolonged illness, antibiotic therapy and/or hospitalizations.

Inspectors wroteBased on observation, interview and record review the facility failed to consistently offer and provide snacks at bedtime for seven residents (#4, #5, #28, #32, #37, #39, #40) of 7 residents reviewed for nightly nutrition. Resulting in, feelings of frustration, unmet needs and residents going longer than 14 hours between dinner and breakfast. Findings Include: During a confidential Resident Council meeting held on 10/29/2024 at 11:30 AM, the twelve residents in attendance were queried if nighttime snacks are offered by facility staff. Eleven of the twelve residents in attendance stated they are not consistently being offered snacks at night. They shared at times when they request snacks, the staff will say they do not have any available snacks for the residents. [...]

Inspectors wroteBased on interview, and record review the facility failed to implement and maintain an Antibiotic Stewardship Program and failed to ensure accurate and timely monitoring and documentation of antibiotic use resulting in the potential for inappropriate antibiotic utilization and the worsening or non-improving infections for all 84 Residents residing within the facility as well as the potential for antibiotic resistance.

Inspectors wroteBased on observation, interview and record review the facility failed to respect the resident's choice to refuse a room change for one resident (Resident #64) of one resident reviewed for choices, resulting in feelings of sadness and hopelessness.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate notice of non-coverage and maintain documentation for two residents (Resident #76 and Resident #187) of five residents reviewed resulting in the lack of full disclosure related to Medicare rights and inability to appeal the discharge in the time frame allotted by Medicare.

Inspectors wroteBased on observation, interview and record review the facility failed to complete continued assessment and monitoring for physical restraints for one resident (Resident #75) of one resident reviewed for restraints, resulting in Resident #75 having a chest harness with four non-self-release buckles. Finding Include: Resident #75: During initial tour on 10/28/2024 at 1:20 PM, Resident #75 was observed in the common area with other residents and staff. He was seated in a customized chair with a harness seatbelt, that secures in four spots. It did not appear Resident #75 would be able to remove the harness himself. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain weights timely for 2 Residents (#9, #80), resulting in unassessed weight loss with the potential of unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accuracy of enteral feeding orders for one resident (#80), resulting in Resident #80's enteral feeding material order to be incomplete, with the potential for enteral tube malfunction/weight loss.

Inspectors wroteBased on interview and record review, the facility failed to implement a procedure for effective communication and coordination of care with dialysis for one resident (Resident #41) of one resident reviewed, resulting in a lack of communication regarding vaccine administration, Resident #41 receiving duplication vaccinations, and the potential for side effects, ongoing lack of communication, and duplicate medication therapy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that three residents (#75, #80 and #82) of 5 residents reviewed for unnecessary medications had adequate indications for usage, care plan implementation and appropriate monitoring, resulting in the increased potential for serious adverse side effects and adverse reactions, and the inability to monitor the effectiveness of antipsychotic and hypnotic medication treatment due to lack of documented supporting evidence. Findings Include: Resident #75: During initial tour on 10/28/2024, Resident #75 was observed in the common area with other residents and staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to prevent pre-set up medications to be found in 2 of 5 medication carts, 2) Failed to prime a new insulin pen prior to administration, and 3) Failed to provide insulin administration timely and per a physician's order for 1 resident (Resident #5), resulting in a medication error rate greater than 5%, and the potential for wrongful administration of pre-set up medications and unmanaged medical conditions requiring therapeutic drugs with the potential for complications and increased blood glucose levels.

Inspectors wroteBased on interview and record review the facility failed to provide dental services to one resident (R19) of one resident reviewed for dental services, resulting in the resident not receiving routine dental services since admission.

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize policies and procedures for vaccination administration for three residents (Resident #1, Resident #56, and Resident #75) of five residents reviewed, resulting in the lack of administration of desired and appropriate vaccinations, and the potential for disease acquisition, transmission, and decline in overall health status.

Inspectors wroteThis Citation pertains to Intake Number MI00146372. Based on interview and record review, the facility failed to implement and operationalize abuse prohibition policies and procedures to ensure adequate supervision to prevent non-consensual sexual behaviors and actions for two residents (Resident #705 and Resident #706) of five residents reviewed for abuse. This deficient practice resulted in a lack of timely reporting and comprehensive investigation of abuse allegations, a lack of supervision to prevent non-consensual sexual actions between cognitively-impaired residents in the locked Dementia Unit of the facility. Resident #705 and Resident #706 were found partially naked in bed with genitals exposed by staff. Resident #705 was displaying ongoing inappropriate sexual behaviors with the likelihood for psychosocial distress using the reasonable person concept.

Inspectors wroteThis Citation pertains to Intake Numbers MI00142793 & MI00143087. Based on the interview and record review, the facility failed to honor the resident's wishes and identify the designated patient advocate, despite legal documentation brought in by the family, upon admission to clearly establish the resident's wishes of Do Not Resuscitate (DNR) for one resident (Resident #801) of three sampled residents reviewed for residents' rights and honoring the resident's and designated patient advocate's wishes for Do Not Resuscitate (DNR) resulting in Resident #801 receiving Cardiopulmonary Resuscitation (CPR) for approximately over an hour and later dying as witnessed by Resident #801's Designated Patient Advocates who were present to witness Resident #801 receiving CPR until Resident #801 was pronounced dead by the Emergency Medical Team (EMT) Ambulance who responded to the 911 call.

Inspectors wroteThis Citation pertains to Intake Number MI00145334 Based on interviews and record review, the facility failed to follow the facility policy to immediately report, conduct an investigation, and inform the local authorities, per facility policy, for one missing resident (Resident #802) of one sampled resident, whose whereabouts were unknown over 24 hours, resulting in the potential for harm from not receiving scheduled medications.

Inspectors wroteThis Citation pertains to Intake Numbers MI00142793, MI00143087, MI00143556, and MI00145334. Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two residents (Resident #801 and Resident #802) reviewed for care planning by 1) Failing to address Resident #801's Advanced Directive and 2) Failing to address Resident #R802's frequent Leaves of Absence out of the facility, resulting in lacking a care plan with resident-specific interventions, staff actions, resident's/advocate's preferences of advanced directives (R801) and leave of absence status (R802) and a lack of clarity and directions specific to staff actions and interventions to deliver patient-centered care.

Inspectors wroteThis Citation pertains to Intake Number MI00143087. Based on interview and record review, the facility failed to follow the wishes of one resident (Resident #801) pertaining to Do Not Resuscitate (DNR) of 5 residents reviewed for Code Status, resulting in Resident #801 receiving a Full Code status not honoring the resident/patient advocate's wishes due to delay caused by the facility and potential for injury, pain and suffering for the resident to experience Cardiopulmonary Resuscitation (CPR) and the resident's family DPOA to witness CPR given to Resident #801 against their wishes.

Inspectors wroteThis citation pertains to Intake #MI00139971 Based on observation, interview, and record review the facility failed to ensure that food was served and held at a palpable temperature. Resulting in the potential to affect all residents (total facility census of 81) that consume food from the kitchen. Findings Included: Resident #25 (R25) Review of the medical record demonstrated that R25 was admitted to the facility 10/04/2022 with diagnoses that included type 2 diabetes, malignant neoplasm (cancer) of the endometrium (lining of the uterus) , atrioventricular block (heart block), anxiety, muscle wasting and atrophy, depression, cerebral infarction (stroke), hemiplegia (paralysis) of the left side, anemia (low red blood cell count), gout (build up of uric acid in joints), hyperlipidemia (high fat amount in blood), and hypertension. [...]

Inspectors wroteThis Citation Pertains To Intake MI00139969 Based on observation, interview and record review, the facility failed to develop and implement care plans for 5 residents (R# 4, #23, #38, #60 and #76) of 19 reviewed, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Dispose of expired medications in 3 of 4 medication carts; and 2. Label a Tuberculin vial with an open date in 1 of 2 medication rooms reviewed for medication labeling and storage, resulting in the potential for decreased medication efficacy and side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow acceptable infection control guidelines for hand washing and failed to follow adhere to Enhanced Barrier Precautions resulting in the potential spread of infection and disease to all 81 residents at the facility. Findings Included: During observation on 11/27/2023 at 12:10 pm observed Certified Nursing Aide (CNA) I pass a food tray to room [ROOM NUMBER] and then passed food tray to room [ROOM NUMBER]. CNA I was not observed washing or sanitizing her hands between tray passes. Then CNA I was observed passing at room tray to room [ROOM NUMBER] and was observed moving his box of Kleenex, removing a lid to his drink container then exiting the room without washing or sanitizing her hands and proceeded to pass another food tray to room [ROOM NUMBER]. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain an effective antibiotic stewardship program, including ongoing monitoring of antibiotic use protocols and an ongoing system to monitor antibiotic use. This deficient practice resulted in the potential for the development of Multi Drug Resistant Organisms (MDRO's) within the entire vulnerable facility's population, family members of the facility population, staff, volunteers, contractual providers, and the surrounding community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a call light within reach for 1 resident (#60) and positioned per resident preference for 1 resident (#6) of 19 residents reviewed for accommodation of needs, resulting in impaired resident access to request and receive assist.

Inspectors wroteBased on interview and record review, the facility failed to utilize and maintain complete grievance documentation resulting in grievances not being documented, tracked, and the results of conclusions and/or resolutions not being recorded. This deficient practice has the potential to affect all 81 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 (Resident #23) of 19 reviewed, resulting in an inaccurate MDS assessment and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete the 3878 portion of the Preadmission Screening (PAS)/Annual Resident Review (ARR) and/or failed to notify the State Agency Health Authority for 1 (Resident #9) of 2 residents reviewed for PAS/ARR from a total sample of 19, resulting in the potential for unmet mental health treatment and services.

Inspectors wroteThis Citation Pertain To Intake MI000139969 Based on observation, interview and record review the facility failed to revise care plans for 2 residents ( #6, and #76) of 19 residents reviewed for care plan revisions, resulting in the potential for unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care to one resident reviewed for maintaining activities of daily living (Resident #45), resulting in poor oral hygiene and the potential to decline in other activities of daily living abilities.

Inspectors wroteThis citation pertains to Intake: MI00139969 Based on observation, interviews, and record review the facility failed to provide Activities of Daily Living (ADL), including bathing/showering and oral care, for two dependent residents (#6, #76) out of four resident reviewed for ADL completion resulting in missed bathing/showers, inadequate oral care and potential feelings of embarrassment. Findings Included: [...]

Inspectors wroteThis citation pertains to intake MI00138918 and MI00139969 Based on interview and record review the facility failed to adequately assess the root cause analysis of resident falls and place appropriate fall prevention interventions, after falls, for two residents (#75, #76) of four residents reviewed for accidents and hazards resulting in continued falls and the potential for resident injury. Findings Included: [...]

Inspectors wroteThis citation pertains to intake: MI00139969 Based on interview and record review the facility failed to follow physician orders for constant oxygen therapy and provide appropriate oxygen tubing for one resident (#76) of three residents reviewed for respiratory care resulting in the potential for respiratory complications. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that one Certified Nursing Aides (J) completed 12 hours of in-service education per year and failed to ensure that two Certified Nursing Aide (J and K) had competency evaluations completed on hire/annually of four Certified Nursing Aides competency and in-service records reviewed resulting in the potential for staff to lack the necessary in-service education to adequately meet the needs of the 81 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) J was hired 10/21/2021. CNA J CNA Competency Check List was completed 11/06/2022. Review of CNA J in-service record demonstrated that she only had nine educations in the last year of employment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate clinical justification for the use of antibiotic medication and the continuance of an unnecessary antibiotics for one (#4) of 5 reviewed for unnecessary medication use, resulting in the potential continued use of unjustified antibiotic usage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when seven medication errors were observed from a total of twenty-eight opportunities for one (Resident #23) of four residents reviewed for medication administration when 7 medications were crushed, dissolved, and administered together via PEG (percutaneous endoscopic gastrostomy-a feeding tube) tube resulting in a medication error rate of 25 percent and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate hospice services for one resident (#38) out of one resident reviewed for coordination of hospice services resulting in the potential for care note being provided to resident receiving hospice services and the potential for residents not be fully informed of hospice services provided. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident call system was functioning for one (R6) of 19 sampled residents, resulting in decreased emergent response time and potential resident adverse clinical outcomes. Findings Include Resident #6 (R6) Review of the medical record revealed Resident #6 (R6) was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Quadriplegia, Neurogenic Bladder, feeding tube, Cardiovascular Accident and Depression. According to Resident #6 (R6)'s Minimum Data Set (MDS) dated [DATE], revealed R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R30 is dependent of all activities of daily living, is bedbound and requires all hydration and medication administration to be through her feeding tube. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to post the actual daily Nursing Staffing Data resulting in the potential for all 81 Residents and/or family and/or visitors to be well informed of the facility's staffing information. Findings Included: During observation on 11/29/2023 at 02:45 p.m. the Daily Nursing Staff Hour was posted on a desk in front of the Nursing Station (first entering the units). Review of the Daily Nursing Staff Hour listed the scheduled hours for all nursing staff but did not list any actual hours worked for the date of 11/29/2023. In an interview on 11/29/2023 at 02:46 Nursing Scheduler Q explained that she was responsible for the daily posting of the Daily Nursing Staff Hours. She explained that scheduled hours worked are provided on the posting. [...]