Adams County Manor

In the surveyor’s words

From the most serious findings on record at Adams County Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 13, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the hospital discharge summary, review of the fall investigation, staff interview, and review of the facility policy, the facility failed to provide Resident #64 with a safe transfer using a mechanical lift. Actual Harm occurred to Resident #64 on 10/25/22 when the resident received assistance from two staff persons using a mechanical lift without staff first securing the loop of the lift pad correctly resulting in an avoidable fall with injuries including unspecified fracture of the shaft of the right and left tibia and fibula. This affected one (Resident #64) of three residents reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2026

  Based on observation and staff interview, the facility failed to store food in a manner to prevent food born illness. This had to potential to affect all 69 residents residing in the facility who received food from the kitchen. The facility census was 69 residents.Findings include: 1.Observation on 03/23/26 at 9:21 A.M. of the dry storage area revealed there was a box of dried onion flakes in a bag which was unsealed and open to air. Interview on 03/23/25 at 9:22 A.M. with the Dietary Manager (DM) confirmed the onion flakes were not properly sealed and should have been discarded. 2.Observation on 03/23/26 at 9:23 A.M. of stand-up freezer #1 revealed it contained an undated bag of flour tortillas which were open to air and were undated and unlabeled and an undated and unlabeled milkshake. […]

• No harm, potential for more than minimal, patternF584Mar 26, 2026

  Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident shower floors were maintained in good repair. This affected four (Residents #10, #11, #35, and #38) of the 24 residents sampled for showers. The facility census was 69 residentsFindings include: Observation on 03/23/26 at 1:16 P.M. revealed the shower floor in Resident #10 and Resident #11's bathroom had a large amount of water pooled on top of the tiles. Several floor tiles were cracked, grout was missing between multiple tiles, and the surface of the tiles was uneven. Observation on 03/26/26 at 9:00 A.M. […]

• No harm, potential for more than minimal, patternF880Mar 21, 2024

  Based on observation, interview, and facilities policy review, the facility failed to follow hand sanitation infection control practices during meal tray delivery. This had the potential to affect seven rooms of residents (Residents in rooms #204, #205, #209, #210, #105, #106 and #110). The facility total census was 64. Findings include: Observation on 03/20/24 during lunch meal tray delivery, between 11:40 A.M. and 11:54 A.M., revealed State tested Nurse Aide, (STNA) # 118 delivered the lunch meal tray to Resident room [ROOM NUMBER]. STNA #118 hands touched resident personal items on the overbed table to make room for the meal tray. The STNA #118 removed lids from the bowls of foods, touched the surface of the overbed table and touched the surface of the resident bed. […]

• No harm, potential for more than minimal, isolatedF569Aug 6, 2026

  Based on record review, staff interview, review of billing records, and review of facility admission agreement, the facility failed to ensure a resident was reimbursed for an overpayment within 30 days of discharge. This affected one (#100) of three residents reviewed for resident funds. The facility census was 63. Findings include: Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] and discharged to home on [DATE]. Diagnoses included adult failure to thrive, depression, chronic obstructive pulmonary disease, and essential hypertension.Review of facility billing documents for Resident #100 reveals that billing occurred for [DATE] through [DATE] and payment was made to the facility. […]