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Deficiency Records for Adrian Bay Rehab and Nursing Center
A list of the most recent deficiencies for Adrian Bay Rehab and Nursing Center. 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 Adrian Bay Rehab and Nursing Center. 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? |
|---|---|---|---|---|
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-19 | 2024-08-02 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-07-19 | 2024-08-02 | N |
| Keep all essential equipment working safely. | Health | 2024-07-19 | 2024-08-02 | 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 | 2024-07-17 | 2024-08-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-17 | 2024-08-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-07-17 | 2024-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-17 | 2024-08-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-17 | 2024-08-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-24 | 2023-11-10 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-24 | 2023-11-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-24 | 2023-11-10 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-24 | 2023-11-10 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-10-24 | 2023-11-10 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-10-24 | 2023-11-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-24 | 2023-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-09-22 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-04 | 2023-06-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-04 | 2023-06-12 | 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 | 2023-05-11 | 2023-06-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-11 | 2023-06-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-06-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-11 | 2023-06-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-11 | 2023-06-06 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-11 | 2023-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-11 | 2023-06-06 | 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 | 2023-05-11 | 2023-06-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-11 | 2023-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-11 | 2023-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-06 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-05-11 | 2023-06-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-11 | 2023-06-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-11 | 2023-06-06 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-04 | 2023-06-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-04 | 2023-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | 2023-06-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-04 | 2023-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-04 | 2023-06-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-07 | 2022-04-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-07 | 2022-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-04-29 | 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 | 2022-04-07 | 2022-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-04-29 | N |
| Dispose of garbage and refuse properly. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-04-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-07 | 2022-04-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-07 | 2022-04-29 | Y |
| 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 | 2022-04-07 | 2022-04-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-07 | 2022-04-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-07 | 2022-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-07 | 2022-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-07 | 2022-04-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-07 | 2022-04-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-07 | 2022-04-29 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-10-28 | 2021-11-10 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-10-28 | 2021-11-10 | Y |
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