George Ade Memorial Health Care Center

In the surveyor’s words

From the most serious findings on record at George Ade Memorial Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 12, 2025

  Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents, related to one staff member (CNA 1) assisting a resident with a shower who was care planned for two staff assistance for activities of daily living (ADL's) resulting in the resident falling in the shower and receiving an abrasion to the right knee and a laceration to the right eyebrow that required four sutures. The resident also had a decline in normal functioning related to ambulation after the fall and was diagnosed eight days later with a fractured right hip for 1 of 3 residents reviewed for accidents and supervision. (Resident D)Finding includes: Resident D's record was reviewed on 11/12/25 at 1:18 p.m. […]

• No harm, potential for more than minimal, widespreadF867Dec 2, 2022

  Based on record review, and interview, the facility failed to report and investigate abuse allegations, which also been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by the number of deficiencies cited involving abuse, abuse reporting and abuse investigations. This deficient practice had the potential to affect 44 of 44 residents residing in the facility. Findings include: Interview with the Administrator on 12/2/22 at 2:37 p.m., indicated the Quality Assessment and Assurance (QAA) Committee met at least quarterly and the committee consisted of the Administrator, Director of Nursing, department heads and therapy. […]

• No harm, potential for more than minimal, widespreadF880Dec 2, 2022

  Based on observation, record review and interview, the facility failed to maintain a complete infection control program which ensured ongoing monitoring of patterns and trends of infections. This had the potential to affect all 44 residents who resided in the facility. They also failed to ensure proper hand hygiene was used during wound care for 1 of 2 residents reviewed for pressure ulcers and during a random observation of medication administration (Residents C and 8) Findings include: 1. The Infection Control Program was reviewed on 12/1/22 at 9:12 a.m. The October 2022 Infection Control Log and Grid, indicated there were 11 cases of urinary tract infections (UTI) that month. There was a facility map that was color coded for types of infections. […]

• No harm, potential for more than minimal, widespreadF880Jul 19, 2022

  Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented to properly prevent and or contain COVID-19 related to the following: - Handwashing not completed after resident care (Resident E and Employee 11), - N95 mask and eye protection not worn properly by an employee in a resident area (Employee 8), - Personal protective equipment (PPE) not discarded appropriately related to N95 masks stored in paper bags in/on the isolation carts and on the handrails for 5 residents on isolation for COVID -19 (Residents D, G, H, K, and L) - High touch surfaces (hallway hand rails, ink pens for screening) not sanitized with a disinfectant effective against COVID-19 and contact times for disinfectants not followed per… […]

• No harm, potential for more than minimal, widespreadF885Jul 19, 2022

  Based on record review and interview, the facility failed to ensure residents and resident representatives/families were notified of COVID-19 positive residents timely. This had the potential to affect 44 of the 44 residents who reside in the facility. Finding includes: During an interview with the Director of Nursing on 7/18/22 at 9 a.m., the first employee to be tested COVID-19 positive was on 6/18/22. The following are the dates of employee COVID-19 positive testing: On 6/20/22 - 1 employee On 6/21/22 - 1 employee On 6/22/22 - 2 employees On 6/23/22 - 1 employee On 6/24/22 - 1 employee On 6/25/22 - 1 employee On 6/26/22 - 2 employees On 7/1/22 - 2 employees On 7/4/22 - 1 employee On 7/6/22 - 1 employee On 7/8/22 - 1 employee On 7/9/22 - 1 employee On 7/10/22 - 3 employees On 7/11/22 -… […]