Adrian Bay Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Adrian Bay Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 22, 2026

  This citation pertains to intake #3030201.Based on observation, interview and record review, the facility failed to ensure their transfer status was accurately following resident's plan of care to prevent fall to occur for one resident (R#2) of 3 sampled residents sustaining a fall resulting in a hospital transfer and admitted for Right Rib Fractures 5-10, Right Forehead Hematoma, Right non-displaced Humeral Fracture, and Right Superior Pubic Rami Fracture and pain.Findings include: The facility incident report was reviewed on 6/22/26 at 1:30 PM. It revealed that Resident#2 (R#2) had a Fall on 5/26/26, while being assisted by CNA A to the bathroom. The Certified Nursing Assistant (CNA A) assisted R#2 to ambulate from the wheelchair to the bathroom using a walker without a gait belt. […]

• Actual harm, isolatedF689Sep 7, 2023

  This citation pertains to intake MI00138570. Based on observation, interview, and record review, the facility failed to provide care planned interventions to maintain functional strength to prevent falls, in one of three reviewed for falls (Resident #1), resulting in multiple falls and injuries including a fracture. Findings include: Resident #1 (R1) R1 was observed sitting in her wheelchair on 9/06/23 at 10:55 AM. R1's Minimum Data Set (MDS) dated [DATE] indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a brief performance-based cognitive screener, score of 04 (00-07 Severe Impairment). […]

• Actual harm, isolatedF686May 11, 2023

  This citation pertains to intake MI00131462. Based on observation, interview, and record review, the facility failed to implement pressure ulcer interventions and treatments for two (Resident #28 and Resident #29) of three reviewed, resulting in the worsening of a pressure ulcer for Resident #29 and the potential of a worsening pressure ulcer for Resident #28. Findings include: Review of the medical record revealed R29 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the left heel, diabetes, and chronic kidney disease stage 3. […]

• Actual harm, isolatedF689May 11, 2023

  Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for four (Resident #11, #13, #20, and #464) of five reviewed for accidents, resulting in reoccurring falls (Resident #13), falls with the potential for major injury (Resident #464) and falls with major injury (Resident #11 and #20). Findings Include: Resident #13 Review of an Admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. […]

• Actual harm, isolatedF689Apr 7, 2022

  This citation pertains to Intake MI 582 Based on observation, interview, and record review the facility failed to prevent a fall for one (Resident #60) of three reviewed, resulting in R60 falling out of bed and sustaining a fracture. Findings include: Review of the medical record revealed Resident #60 (R60) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included left femur fracture on 12/1/21, [CONDITION(S)], diabetes, anxiety, and right above the knee amputation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/21 revealed R60 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance of two people for bed mobility. […]