Deficiency Records for Adrian Bay Rehab and Nursing Center
Updated as of August 01, 2021
This is not the most recent data for Adrian Bay Rehab and Nursing Center. For the most recent information, click here.
A list of the most recent deficiencies for Adrian Bay Rehab and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-12-09 | 2021-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-09-03 | 2020-09-30 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-01-09 | 2020-03-23 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2020-01-09 | 2020-03-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-09 | 2020-03-23 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-09 | 2020-03-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-09 | 2020-03-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-09 | 2020-03-23 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-09 | 2020-02-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-09 | 2020-02-19 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-09 | 2020-02-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-01-09 | 2020-02-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-09 | 2020-02-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-09 | 2020-02-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-09 | 2020-02-19 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-09 | 2020-02-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-09 | 2020-02-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-09 | 2020-02-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-09 | 2020-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-09 | 2020-02-19 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2020-01-09 | 2020-02-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-26 | 2019-11-09 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-09-26 | 2019-11-09 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-09-26 | 2019-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-29 | 2019-07-01 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-19 | 2018-12-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-19 | 2018-12-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-19 | 2018-12-26 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-11-19 | 2018-12-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-16 | 2018-12-26 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2018-11-16 | 2018-12-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-11-16 | 2018-12-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-16 | 2018-12-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-16 | 2018-12-26 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-16 | 2018-12-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-16 | 2018-12-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-11-16 | 2018-12-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-11-16 | 2018-12-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-16 | 2018-12-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-16 | 2018-12-26 | N |
| Provide appropriate foot care. | Health | 2018-11-16 | 2018-12-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-11-16 | 2018-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-16 | 2018-12-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-16 | 2018-12-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-11-16 | 2018-12-26 | N |
| Provide or obtain dental services for each resident. | Health | 2018-11-16 | 2018-12-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-11-16 | 2018-12-26 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2018-11-16 | 2018-12-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2018-11-01 | 2018-12-03 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2018-11-01 | 2018-12-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-03 | 2018-10-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-22 | 2018-09-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-22 | 2018-09-15 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-03 | 2017-10-23 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-03 | 2017-10-23 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2017-08-08 | 2017-09-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-08-08 | 2017-09-28 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-08-03 | 2017-09-11 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-03 | 2017-09-11 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-08-03 | 2017-09-11 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-03 | 2017-09-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-08-03 | 2017-09-11 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-03 | 2017-09-11 | N |
