Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adrian Bay Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with sepsis, UTI, prior stroke, and a positive COVID-19 test was prescribed Paxlovid by the primary physician, but the medication was repeatedly not administered as ordered, with MAR entries citing it being on order or unavailable and one dose lacking documentation. Although two doses were charted as given, later review and pharmacy confirmation showed the resident never received Paxlovid because the order was cancelled after a high-cost form from the facility led to its cancellation before delivery. The family was not informed that the resident did not receive Paxlovid, was not told the drug was not covered by insurance, and was not offered the option to obtain it privately. No alternative treatment was started until the resident developed worsening shortness of breath and low O2 saturation, prompting initiation of oxygen, prednisone, nebulizer treatments, and a STAT chest x‑ray.
A resident with sepsis, UTI, cerebral infarction, and a positive COVID-19 test had multiple verbal orders for Paxlovid 300/100 mg BID entered and revised, with the MAR showing several doses marked as not given due to the drug being on order or unavailable, one dose lacking documentation, and two doses recorded as administered by an RN. Progress notes repeatedly stated the medication was not given because it was on order or unavailable, while pharmacy records confirmed Paxlovid was never delivered after the order was cancelled due to high cost, making the documented administrations inaccurate; the RN involved had a prior disciplinary action for falsely documenting medication administration.
Surveyors identified multiple discrepancies in the documentation and administration of controlled substances, including mismatches between the controlled substance book and actual medication counts, as well as numerous instances where medications were signed out as removed but not documented as administered on the MAR. Several residents with chronic pain and other conditions reported not receiving pain medications, and staff raised concerns about possible forged signatures and inconsistent documentation practices. Interviews confirmed that staff were aware of these issues, and investigations had been initiated, but discrepancies continued to occur.
The facility did not report reasonable suspicions of medication theft and forgery involving controlled substances, despite multiple staff and resident reports of missing pain medication and forged signatures on drug records. These concerns were not communicated to the State Agency or law enforcement as required by policy and regulation.
Two residents received controlled pain medications at intervals shorter than ordered by their physicians, and staff failed to consistently document administration on both the MAR and controlled drug records. Nursing staff and the DON confirmed that doses were sometimes given too close together and not properly recorded.
The facility failed to maintain backflow prevention devices, risking contamination of the potable water system. Observations revealed missing air gaps in kitchen sinks and a lack of backflow protection for the steamer. Additionally, chemical dispensers at mop sinks left Atmospheric Vacuum Breakers under pressure, compromising their effectiveness.
A resident with COPD did not receive necessary nebulizer treatments due to a lack of tubing supplies at the facility. This resulted in missed doses of prescribed medications, leading to respiratory distress and increased anxiety. The central supply staff was unaware of the shortage, and the resident eventually left the facility against medical advice due to the lack of treatment.
A resident with dysphagia and a history of stroke was not provided with the appropriate food consistency, despite a speech evaluation recommending a puree diet. The resident continued to receive a soft, bite-sized texture diet, leading to potential risks of aspiration and choking. Family members had to assist in cutting the food into smaller pieces, and staff confirmed the oversight in implementing the correct diet.
Failure to Administer Ordered Paxlovid and Notify Family Regarding High-Cost Cancellation
Penalty
Summary
Failure to administer medications as ordered occurred when a cognitively intact resident with sepsis, UTI, and prior cerebral infarction tested positive for COVID-19 and was prescribed Paxlovid by the primary physician. The initial verbal order for Paxlovid was written on 12/30 with a start date of 12/31, but the first scheduled dose on 12/31 was not given and was documented as awaiting arrival from the pharmacy. Subsequent physician orders for Paxlovid were entered and revised on 12/31, including discontinuation and reordering for a 5‑day course starting 1/1. The MAR showed multiple doses marked as “Other/See Nurse Note” on several days, and one scheduled dose had no documentation at all. Progress notes repeatedly stated that Paxlovid was not given because it was “on order” or “medication unavailable.” Despite MAR entries indicating that two doses were administered, later review confirmed the resident never actually received Paxlovid, and the pharmacy reported the medication was assigned for delivery but cancelled before leaving the pharmacy after a high‑cost form from the facility indicated to cancel the order. The physician’s orders reflected that Paxlovid was cancelled due to being a high‑cost medication. The family was not informed that the resident had not received Paxlovid after it was prescribed, was not told that the medication was not covered by insurance, and was not given the option to obtain it privately. No additional treatment was initiated during this period until the resident developed worsening shortness of breath with an oxygen saturation of 88% on room air, at which point oxygen, prednisone, nebulizer treatments, and a STAT chest x‑ray were ordered.
Inaccurate MAR Documentation for Undelivered Paxlovid Order
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records for a resident who was admitted with sepsis, UTI, and cerebral infarction and was cognitively intact per a BIMS score of 14. The resident tested positive for COVID-19, and a verbal physician order was obtained for Paxlovid 300/100 mg BID for 5 days, scheduled to start the following day. The initial dose on the first scheduled morning was not given and was marked on the MAR as “Other/See Nurse Note,” with progress notes indicating the medication was awaiting arrival from the pharmacy. The original Paxlovid order was discontinued and replaced with a second order for a split 4-day and 1-day regimen, which was then discontinued the same day, followed by a third verbal order for Paxlovid 300/100 mg BID for 5 days starting the next day. Subsequent MAR entries showed multiple doses marked as “Other/See Nurse Note” on several mornings and evenings, and one scheduled morning dose had no documentation at all. Two doses were documented as administered by an RN, while multiple progress notes over several days stated that Paxlovid was not given because it was on order or unavailable. Pharmacy records later confirmed that Paxlovid was never delivered to the facility because the order was cancelled after a high-cost form was returned indicating cancellation, and the physician’s orders reflected that the medication was cancelled due to high cost. The DON determined that the two doses documented as given were inaccurate, and the RN who documented those administrations had a prior disciplinary action for documenting a medication as given when it was not administered. No disciplinary action specific to the inaccurate Paxlovid documentation was found in the RN’s personnel file.
Failure to Maintain Accurate Controlled Substance and Medication Administration Records
Penalty
Summary
The facility failed to maintain accurate controlled substance and medication administration records for multiple residents, as well as for two medication carts. Surveyors observed discrepancies between the number of controlled medications recorded in the controlled substance book and the actual count in the medication carts. For example, one cart was documented as containing 45 controlled medications, but only 44 were present. In another instance, a controlled drug record indicated 17 mL of morphine concentrate remained, while the actual amount in the bottle was approximately 23 mL. Staff interviews revealed inconsistent practices in counting and documenting controlled substances, with some nurses reporting that medications were signed out on the controlled drug record but not on the medication administration record (MAR), and vice versa. Review of records for several residents revealed numerous instances where controlled medications were signed out as removed from the medication cart but were not documented as administered on the MAR. In some cases, the times recorded on the controlled drug record and the MAR did not match, and in others, signatures were suspected to be forged. Residents reported not receiving pain medications that were documented as administered, and staff expressed concerns about possible signature forgeries and discrepancies in medication documentation. These issues were noted across multiple residents with various diagnoses, including chronic pain, cancer, sepsis, osteoarthritis, and fractures. Interviews with nursing staff and the DON confirmed awareness of ongoing discrepancies and concerns regarding the administration and documentation of controlled substances. Staff described processes where medications were removed from the cart and documented on the controlled drug record, but not always immediately signed out on the MAR, especially if there was uncertainty about whether the resident would take the medication. Investigations into signature authenticity and medication administration were initiated after staff raised concerns, but discrepancies persisted, as evidenced by the surveyors' findings during their review.
Failure to Report Suspected Medication Theft and Forgery
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the suspected forgery of staff signatures and the administration of controlled medications. Two residents were directly affected: one resident reported not receiving prescribed Norco pain medication on two occasions, despite documentation indicating it had been administered. The resident, who was cognitively intact, described experiencing severe pain after wound care and being told by a nurse that she could not receive additional medication due to records showing it had already been given. Review of the medication administration records and controlled drug logs revealed discrepancies, including doses signed out but not documented as administered. Multiple staff members, including LPNs and RNs, reported concerns about signatures being forged on controlled drug records and medications being signed out without being administered to residents. These concerns were reported to supervisors and the DON, with some staff specifically noting that their signatures appeared on records for dates they did not work or did not administer medication. Despite these reports and ongoing suspicions since at least May, there was no evidence that the facility reported these allegations of forgery and potential medication diversion to the State Agency or law enforcement, as required by facility policy and federal regulations. The facility's own abuse and neglect policy mandates immediate reporting of all allegations or suspicions of abuse, including potential crimes such as medication theft or forgery, to both the State Agency and law enforcement. The policy also requires a final investigation report to be submitted within five working days. However, the investigation file provided by the facility did not contain documentation of such reports being made, nor was there evidence that the allegations were communicated to the appropriate authorities within the required timeframes.
Failure to Administer Controlled Medications per Physician Orders and Document Properly
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents. For one resident with polyneuropathy and low back pain, the physician's order specified hydrocodone-acetaminophen 5-325 mg to be given every six hours as needed for pain. However, review of the controlled drug record showed that doses were administered at intervals shorter than six hours on multiple occasions, and some doses were not documented on the Medication Administration Record (MAR) as required. The resident was cognitively intact and reported taking the medication as needed for pain. For another resident with acute respiratory failure, COPD, and diabetes with neuropathy, the physician's order was for oxycodone HCl 5 mg by mouth every six hours as needed for pain. Documentation revealed that doses were signed out at intervals less than six hours apart on several dates, and there were discrepancies between the MAR and the controlled drug record, including illegible times and missing documentation. Interviews with nursing staff and the Director of Nursing confirmed that controlled medications were not consistently documented in both the MAR and the proof of use sheets, and that some doses were administered too close together, contrary to physician orders.
Failure to Maintain Backflow Prevention Devices
Penalty
Summary
The facility failed to install and maintain backflow protection devices and air gaps, which could potentially contaminate the potable water system affecting all residents. During an inspection of the kitchen, it was observed that the drain lines of the three-compartment sink and the vegetable and fruit preparation sink were not provided with an air gap to prevent backflow of contaminants. The Dietary Manager confirmed these findings. Additionally, the steamer at the cookline lacked a backflow protection device, which is necessary to protect the potable water supply. Further observations revealed that the dietary mop sink had a wall-mounted chemical dispenser connected to the water fixture, with the water left on, using the chemical dispenser as a shut-off valve. This left the Atmospheric Vacuum Breaker (AVB) under pressure, which can compromise its integrity and effectiveness. Similarly, the housekeeping office mop sink was found to have a wall-mounted chemical dispenser connected to the water fixture, with the AVB under pressure. These deficiencies are in violation of the 2017 FDA Food Code requirements for backflow prevention devices.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident, resulting in missed doses of physician-ordered nebulizer treatments. The resident, who was admitted with chronic obstructive pulmonary disease (COPD) and other health conditions, did not receive the required breathing treatments due to the unavailability of nebulizer tubing. This led to the resident experiencing respiratory distress and increased anxiety, as well as difficulty in breathing, which was observed during multiple interviews and observations. The facility's central supply staff was responsible for ordering oxygen tubing supplies but was not aware that the facility had run out of nebulizer tubing. As a result, the resident missed several doses of prescribed medications, including Budesonide and Ipratropium-Albuterol inhalation solutions. Despite the resident's family discussing alternative options with the unit manager, the resident continued to experience breathing difficulties and eventually signed out against medical advice due to the lack of treatment. Interviews with the Director of Nursing and other staff revealed that the facility did not have a sufficient supply of nebulizer tubing on hand, and the staff failed to notify the physician about the missed treatments in a timely manner. The facility's policy required that nebulizer treatments be administered as ordered by a physician, but this was not adhered to, leading to the resident's medical decline and eventual departure from the facility.
Failure to Implement Appropriate Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to provide the appropriate food consistency for a resident with dysphagia and a history of stroke, leading to potential risks of aspiration and choking. The resident, who was cognitively intact, expressed difficulty in chewing food and reported weight loss. Despite having a physician's order for a soft, bite-sized texture diet, a speech evaluation on 7/2/24 indicated that the resident's diet should have been downgraded to a puree consistency due to coughing and choking during meals. However, this change was not implemented, and the resident continued to receive the incorrect diet. Interviews with family members and staff revealed that the resident's food was not adequately prepared to meet her needs, requiring family members to assist in cutting the food into smaller pieces. The Registered Dietician and Dietary Manager both confirmed that the speech evaluation recommending a puree diet was overlooked, resulting in the resident receiving an inappropriate diet. This oversight highlights a failure in communication and adherence to dietary orders, which could have serious implications for the resident's health and safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Adrian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lynwood Manor Healthcare Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Springcreek Rehabilitation And Nursing Center | 1.9 mi | ★★★★★ | 22 | 0 |
| Lenawee Medical Care Facility | 2 mi | ★★★★★ | 17 | 0 |
| Otterbein Sunset Village | 19.4 mi | ★★★★★ | 5 | 0 |
| Lakes Of Sylvania, The | 20.4 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.