Adams Farm Living & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Adams Farm Living & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF580May 1, 2025

  Based on record review and interviews with RP (Responsible Party), staff, Nurse Practitioner (NP), and Physician the facility failed to notify the RP when Resident # 1's seizure medication was discontinued. Interview with the RP revealed if she had been notified, she would have been an advocate for Resident # 1 and informed the facility that the resident's seizure medication was not to be discontinued prior to a neurologist evaluating the resident and making the decision. Resident # 1 seized following the seizure medication discontinuation and was hospitalized in the Intensive Care Unit. This was for one (Resident #1) of three sampled residents whose medications were reviewed. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF684May 1, 2025

  Based on record review and interviews with staff, Physicians, Nurse Practitioners (NPs), and Responsible Party (RP) the facility failed to ensure a resident (Resident #1) received follow-up for a newly diagnosed disorder per a plan of care set forth upon discharge from the hospital and received seizure medication. Resident # 1 was hospitalized from 11/4/24 to 11/15/24 with diffuse encephalopathy (disease of the brain that alters brain function and structure) and seizure like activity. Hospital discharge plans on 11/15/24 included orders for a seizure medication (Keppra) and directions that Resident # 1 should follow up with neurology. The facility never arranged a neurology follow-up visit as directed. […]

• Actual harm, isolatedF711May 1, 2025

  Based on record review, and staff, Physician, and Nurse Practitioner (NP) interview the facility failed to ensure during visits the providers reviewed the total plan of care for Resident # 1's newly diagnosed neurological disorder when there was a change in primary providers and collaborative health care providers added to health care decision making for the resident. Multiple providers saw Resident # 1 and failed to recognize the hospital discharge plan was to have the neurologist see the resident and no appointment had been set up for her and completed prior to discontinuation of her seizure medication. On 2/12/25 Resident # 1's seizure medication was discontinued. Interviews with Resident # 1's NP and Physician revealed neither recalled giving the order. […]

• No harm, potential for more than minimal, patternF761Aug 21, 2024

  Based on record review, observation and staff interviews the facility failed to label medications which were not stored in the pharmacy or manufacturer packaging (500 hall medication cart for medication storage review for 2 of 3 medication carts reviewed) . 1.An observation of the 400-hall medication cart was conducted on 08/21/24 at 10:49 AM in the presence of Nurse #3 and Nurse #4. The medication cart contained 4 loose pills of various shapes, colors, and sizes on the bottom of cart drawers. Nurse #4 indicated each nurse assigned to the medication cart was responsible for cleaning the medication cart they were assigned to, ensuring it was organized, and well stocked. An interview was conducted with the Director of Nursing on 08/21/24 at 11:15 AM. […]

• No harm, potential for more than minimal, patternF812Aug 21, 2024

  Based on observations, record review, and interviews of staff, the facility failed to clean the top and bottom ovens as evidenced by brown and black soiling for 2 of 2 ovens, and the facility failed to label and date perishable food items when opened or date when to discard in the walk-in refrigerator. These practices had the potential to affect food served to residents. Findings included: 1. On [DATE] at 9:55 am an interview and observation of the kitchen was done with the Dietary Manager in training. Observation of the 2 ovens' tops and bottoms had burnt on food stains and burnt food debris on the bottom pan and brown and black soiling on the interior walls and racks. […]