Adams Lane Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Adams Lane Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610Feb 1, 2023

  Based on record review, review of a local law enforcement investigation into an incident of suspected sexual abuse related to facility self-reporting incident (SRI) tracking number 231321, staff interview, and review of the facility Abuse policy and procedure, the facility failed to ensure actual, suspected, or potential incidents of verbal, mental, physical and sexual abuse were timely identified, reported, and investigated when they occurred to Resident #76, a cognitively impaired resident who resided on the facility secured memory care unit. Between 01/02/23 and 01/21/23, facility staff identified and/or observed incidents of interactions reflective of abuse towards Resident #76 by her husband, while he was visiting in the facility. […]

• Immediate jeopardy, isolatedF600Jul 23, 2025

  THE 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. […]

• Immediate jeopardy, isolatedF678Sep 6, 2023

  THE 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. […]

• Immediate jeopardy, isolatedF600Feb 1, 2023

  Based on record review, review of facility self-reported incident (SRI) tracking number 231321, review of the facility's investigation related to the SRI, review of law enforcement reports, staff interview, and review of the facility Abuse and Visitation policy and procedures, the facility failed to ensure Resident #76, who was cognitively impaired and resided on the secured memory care unit was free from verbal, mental, physical, and potential sexual abuse following admission to the facility on [DATE]. Between 01/02/23 and 01/21/23, the facility's staff identified and/or observed at least five incidents of interactions reflective of abuse toward Resident #76, by her husband, while he was visiting in the facility. […]

• Actual harm, isolatedF684Sep 27, 2021

  Based on record review, facility policy and procedure review and interview the facility failed to provide timely and adequate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 07/02/21 when Resident #75, who was severely cognitively impaired and required staff assistance for bed mobility and transfers, sustained a fall which resulted in bruising and swelling to her hip but was not immediately sent to the hospital for evaluation/treatment. From 07/02/21 to 07/09/21 the resident exhibited increased pain and agitation, yelling out for help and rated her pain up to a nine on a scale of one to 10 (with 10 being the worst pain). […]