Adams Lane Healthcare and Rehabilitation Center

Inspectors wroteBased on observations, staff interview, family interview, and policy review, the facility failed to ensure the residents right to privacy of personal and clinical information. This affected four residents (#17, #29, #33, and #35) of 38 residents reviewed for personal privacy. The facility census was 107.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy and procedure review, the facility failed to maintain a clean and homelike environment. This was observed in four units (100, 200, 300 and 700) of seven units in the facility and affected five residents (#26, #33, #85, #97, and #107) of 107 residents reviewed for their environment. The census was 107.

Inspectors wroteBased on observations, staff interview, and review of menus and recipes, the facility failed to ensure food was prepared by methods that conserve nutritive value. This affected four of four residents who received a pureed diet (Residents #9, #31, #33, and #80). The facility census was 107.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure that resident personal food items were stored appropriately in nursing unit refrigerators. This affected Resident #79 but had the potential to affect the residents residing on four (Unit 300, 400, 600 and 700) of five nursing units. The facility census was 107. Observations on 06/03/26 at 8:30 A.M. of the nursing unit refrigerator on the 300/400 unit revealed two takeout food containers containing Chinese food and a burrito. The takeout containers were not labeled with a resident name and were not dated to indicate when they were placed in the refrigerator or when they were to be discarded. Observations on 06/03/26 at 8:35 A.M. of the nursing unit refrigerator on the 600 unit revealed a bag containing food from Taco Bell dated 05/28/26. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to maintain infection control principles as evidenced by open packages of incontinence products stored on the floor, gloves not being changed when needed while checking a finger stick blood sugar, not covering the end of a tube feeding line after unhooking it from a resident and not maintaining a resident's urinary catheter tubing off of the floor. This affected five resident's (#4, #43, #64, #85 and #92) of eight sampled for infection control. The facility census was 107.

Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy and procedure, the facility failed to maintain a resident's dignity with use of an indwelling urinary catheter. This affected one resident (#4) four residents observed with indwelling urinary catheters. The census was 107.

Inspectors wroteBased on observation, interview and record review the facility failed to individualize a resident's room to allow the resident to access all areas of the room. This affected one resident (#64) of one resident reviewed for reasonable accommodation of need. The facility census was 107.

Inspectors wroteBased on record review, interview and review of facility policy the facility failed to ensure a resident's physician was notified when a resident was transferred to the hospital. This affected one resident (#112) of three residents reviewed for discharge. The facility census was 107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident was free from chemical restraints when a psychoactive medication was given without attempting non-pharmacological interventions and without adequate indication for use. This affected one resident (#103) of five residents reviewed for unnecessary medications. The facility census was 107.

Inspectors wroteBased on record review and staff interview, the facility failed to conduct a comprehensive assessment for a resident with a diagnosis of post traumatic stress disorder (PTSD). This affected one resident (#67) of 38 residents reviewed for comprehensive assessments. The facility census was 107.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to develop a comprehensive care plan. This affected one resident (#33) of 38 residents reviewed for comprehensive care plans. The facility census was 107.

Inspectors wroteBased on medical record review and staff interview the facility failed have timely care conferences and invite family to care conferences. This affected two residents (#3, #35) of five residents reviewed for care plan timing and revision. The census was 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to follow physician orders for monitoring urinary output. This affected one resident (#4) of four residents reviewed with indwelling urinary catheters. The census was 107.

Inspectors wroteBased on record review, observation, interview and review of the manufacture user guide, the facility failed to ensure a physician ordered low air loss mattress for pressure ulcer prevention was was powered and inflated. This deficient practice affected one resident (Resident #27) of four residents reviewed for medical equipment. The census was 107.

Inspectors wroteBased on record review, observations, interviews, and facility policy review the facility failed to ensure safety of residents was maintained. This deficient practice affected one resident (Resident #12) out of four residents reviewed for safety adaptive equipment for cigarette smoking, affected one resident (Resident #44) out two residents for safety while out on the facility's campus, and affected one resident (Resident #71) out three residents reviewed for bed mattress safety. The facility census was 107. Findings Include: 1. Review of Resident #12's medical record revealed an admission date 09/29/25 with diagnoses including but not limited to Multiple Sclerosis, high blood pressure, depression, anxiety, and paraplegia. Review of Resident #12's smoking assessment dated [DATE] revealed Resident #12 was deemed supervision for smoking with no adaptive equipment or smoking apron required. [...]

Inspectors wroteBased on medical record review, observation, staff interview and facility policy and procedure review, the facility failed to follow physician orders for flushing the gastrostomy tube (tube through the abdominal wall into the stomach for nutrition) during medication administration . This affected one (Resident #85) of one resident observed for medication administration through a gastrostomy tube. The census was 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure medications were administered within ordered physician parameters. This affected one (Resident #3) of five residents reviewed for unnecessary medications. The census was 107.

Inspectors wroteBased on medical record review, staff, and resident interview, the facility failed to obtain dental services for one (Resident #3) of nine residents reviewed for dental services. The census was 107.

Inspectors wroteBased on medical record review, staff, and resident interview, the facility failed to obtain dental services for one (Resident #10) of nine residents reviewed for dental services. The census was 107.

Inspectors wroteBased on record review, observation, and interview the facility failed to maintain accurate medical records related to pressure relieving interventions. This deficient practice affected one resident (Resident #27) of four residents reviewed for medical equipment. The census was 107. Findings Include:Review of Resident #27's medical record revealed admission date 12/31/23 with diagnoses including but not limited to type two Diabetes Mellites, heart failure, Alzheimer's Disease, and high blood pressure. Review of Resident #27's signed physician orders revealed an order dated 11/06/25 for use of a Low Air Loss (LAL) mattress to bed. Check function/inflation every shift (QS). [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, review of a facility self-reporting incident (SRI), review of the facility's related investigation, staff interview, resident interview, family interview, and review of the facility's Abuse Policy, the facility failed to protect Resident #14's right to be free from sexual abuse by Resident #97. This resulted in Immediate Jeopardy and actual harm beginning on 07/08/25 at 7:20 P.M. when Certified Nursing Assistant (CNA) #119 observed Resident #97, who had a history of sexually inappropriate behaviors engaged in non-consensual sexual intercourse with Resident #14, a cognitively impaired and non-interviewable female resident, who lacked the cognitive ability to provide consent to sexual activity. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a safe homelike environment for the 22 (Residents #58, #59, #60, #61, #62, #62, #63, #64, #65, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, and #80) in the memory care unit when the unit was left with a black moldlike substance in the hallway, and there was a strong odor of urine noted throughout the unit. This affected 22 residents in memory care unit of 94 residents reviewed for environment. The facility census was 94.

Inspectors wroteBased on observation, record review, interview, and review of the facility policies, the facility failed to maintain appropriate infection control and enhanced barrier precautions (EBP) for one (Resident # 87) out of 41 residents in EBP. The facility census was 94.

Inspectors wroteBased on medical record review, staff interview, resident interview, vendor staff interview, and facility policy review, the facility failed to provide medically necessary social services regarding discharge processes. This affected one (Resident #11) of three residents reviewed for discharge. The census was 108. Findings Include: Resident #11 was admitted to the facility on [DATE]. Her diagnoses were congestive heart failure, chronic respiratory failure with hypoxia, hypo-osmolality and hyponatremia, atrial fibrillation, gout, anemia, hypertension, anxiety disorder, glaucoma, bipolar disorder, fibromyalgia, COPD, and depression. Review of her minimum data set (MDS) assessment, dated 03/14/25, revealed she was cognitively intact. Review of Resident #11's quarterly care conference notes, dated 11/04/24, 01/27/25, and 04/21/25 revealed the facility addressed on-going discharge questions. [...]

Inspectors wroteBased on observation, staff and resident interviews, and record review the facility failed to provide reasonable accommodation of needs and preferences when a bedside chair, a bedside nightstand, and a call light were not within reach. This affected one of 108 residents (#26). The facility census was 108. Findings Include: Record review revealed Resident #26 had an admission date of 05/19/23 with diagnoses including: [...]

Inspectors wroteBased on record review, observation, staff and resident interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for two residents which allowed them to use their personal belongings to the extent possible This affected three residents (#33, #40, #75) of 108 residents residing in the facility. The census was 108. Findings Include: 1. Record review revealed Resident #40 had an admission date of 03/30/18 with diagnoses including: [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident reviews (PASSAR) were accurately completed. This affected one resident (#43) of two review for PASSAR accuracy. The census was 108.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person centered care plan for diuretic medication for Resident #60. This affected one resident (#60) of five residents sampled for unnecessary medications. The facility census was 108.

Inspectors wroteBased on observation, staff interview and review of facility policy and procedure, the facility failed to ensure medications were locked against unauthorized access. This had the potential to affect one resident (#97) of 10 residents on the 200 hallway identified as cognitively impaired and independently mobile. The census was 108.

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to maintain infection control with urinary catheters. This affected one resident (#3) of four residents reviewed for urinary catheters. The census was 108.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure written information prior to transfer to the hospital of the bed hold notice. This affected three residents (#61, #71 and #106) of three residents reviewed for hospitalization. The census was 108.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of an emergency medical services (EMS) report, interviews with facility staff and review of facility Code Status policy the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #94. This resulted in Immediate Jeopardy and the actual serious life-threatening harm and death on [DATE] beginning at 5:22 A.M. when Resident #94, who had advance directives for cardiopulmonary resuscitation/full code status, was found unresponsive, without a pulse, and was not provided CPR. The facility notified EMS for hospital transport without completing a comprehensive assessment of the resident ' s status. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure advance directive orders and documents were consistent in the medical record and reflective of the resident/resident representative wishes. This affected one (Resident #348) of 24 residents reviewed for advance directives. The facility census was 100.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure a significant change assessment was initiated when a resident was admitted to hospice services. This affected one (Resident #91) of 21 residents who were reviewed regarding requirements for significant change assessments. The census was 100.

Inspectors wroteBased on medical record review, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when funds were above the Medicaid allowable limit. This affected three (Residents #19, #23, and #37) of six resident financial information reviewed. The census was 100. Findings Include: 1. Resident #19 was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease, major depressive disorder, anxiety disorder, and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she had a significant cognitive impairment. Review of Resident #19's quarterly financial statements, dated 07/01/22 to 06/30/23, revealed her total amount in her resident account varied between $2986.96 and $7191.37; it was never below $2000. [...]

Inspectors wroteBased on observations, policy review, review of drug reference information and interview, the facility failed to ensure medications were appropriately labeled and stored. This affected six residents (Resident #21, #29, #65, #67, #89 and #93) of 100 residents residing in the facility.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure antibiotic stewardship guidelines were followed prior to antibiotic use. This affected one (Resident #299) of one resident reviewed for antibiotic stewardship. The census was 100. Findings Include: Resident #299 was admitted to the facility on [DATE]. Her diagnoses were sepsis, rectal abscess, difficulty walking, type II diabetes, muscle weakness, chest pain, obesity, anemia, vitamin D deficiency, tobacco use, hypertension, major depressive disorder, osteoarthritis, fibromyalgia, and headache. Review of her Minimum Data Set (MDS) assessment, dated 08/14/23, revealed she was cognitively intact. Review of Resident #299 physician orders revealed she was prescribed Doxycycline Hyclate Oral Tablet 100 milligrams, twice daily for seven days. [...]