Adamsville Healthcare and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Jul 30, 2025

  Based on observation and interview, the facility failed to ensure kitchen sanitation when a black slimy substance was found inside 1 of 3 (500-hall ice machine) ice machines observed. There were 8 residents on the 500-hall who had the potential to be affected. The findings include: Observation of the 500-hall ice machine on 7/29/2025 at 3:05 PM, revealed a black slimy substance noted on the right and left inside walls of the ice machine and along the length of the ice tray. Observation and interview of the 500-hall ice machine on 7/29/2025 at 3:30 PM, the Dietary Manager (DM) confirmed the black slimy substance was there and stated, .I see what you are talking about. That should not be there. During an interview on 7/30/2025 at 8:09 AM, the Administrator stated, . […]

• No harm, potential for more than minimal, isolatedF695Jul 30, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders and to monitor the oxygen flow rate for 2 of 2 (Resident #11 and #27) sampled residents reviewed for respiratory therapy. The findings include: 1. Review of the undated facility policy titled, Providers Orders, revealed .This facility shall use uniformed guidelines for the ordering of medication.Medication should be administered only upon the signed order of a person lawfully authorized to prescribe.Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). […]

• No harm, potential for more than minimal, isolatedF880Jul 30, 2025

  Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 5 nurses (Licensed Practical Nurse (LPN) A) failed to disinfect reusable resident equipment for 1 of 5 (Resident #61) residents observed during medication administration. The findings include: 1. Review of the facility's undated policy titled, Cleaning and Disinfection of Resident- Care Equipment, revealed Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection. […]

• No harm, potential for more than minimal, isolatedF760Aug 4, 2021

  Based on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 1 of 6 nurses (Licensed Practical Nurse (LPN) #1) failed provide a substantial snack or meal within 15 minutes of insulin administration for Resident #60. The failure to provide a substantial snack or meal within 15 minutes of insulin administration resulted in a significant medication error. The findings included: The GERIATRIC MEDICATION HANDBOOK, 13TH edition, provided by the American Society of Consultant Pharmacists, page 41 and 43, revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Insulin [MEDICATION(S)] .Rapid-Acting Insulin Analog .Onset .15 min [minutes] .ADMINISTRATION/COMMENTS . […]

• No harm, potential for more than minimal, isolatedF761Aug 4, 2021

  Based on observation and interview, the facility failed to ensure opened medications were properly labeled and dated, external and internal medications were not stored together, and medications were not stored past their expiration date in 4 of 11 medication storage areas (100/200 Hall Medication Cart, 200/500 Hall Medication Cart, 400 Hall Medication Cart, and 400 Hall Treatment Cart). The findings include: Observation of the 400 Hall Medication Cart on 8/2/2021 at 12:01 PM, revealed the following: a. 2 open undated [MEDICATION(S)] vials b. 1 open Ultratuss bottle (a medication taken by mouth) in the same drawer as Theraworx Relief cream (a topical medication) Observation of the 200/500 Hall Medication Cart on 8/2/2021 at 4:53 PM, revealed the following: a. […]