Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Baptist Homes Of Adrian during CMS and state inspections, most recent first.
Failure to complete CNA performance reviews and regular in-service training: The facility did not complete annual performance reviews for three sampled CNAs and did not provide consistent in-service education. Staff reported training was mostly computer-based, there had been no recent skills fairs, and the DON said there was no system to ensure training hours and performance reviews were completed and that CNA training was done but not documented.
Failure to complete and track monthly MRRs: the contracted pharmacist did not complete monthly drug regimen reviews for three sampled residents, including residents with cognitive impairment and diagnoses such as thyroid disorder, anxiety, seizure disorder, depression, and DVT. The DON said there had been ongoing issues with the MRR process, a prior PIP could not be located, and physician responses for the reviews were not being tracked or documented as expected.
Unsafe food labeling and storage practices were observed in the dietary area. Multiple opened food items lacked date-opened labels, some foods were expired or not securely sealed, and one opened sauce required refrigeration after opening but was not refrigerated. Dietary staff and the DM stated that opened foods were expected to be labeled, checked for dates before serving, and refrigerated when indicated by the manufacturer.
Infection control practices were not followed during wound care for one resident with a skin tear and nonsurgical dressings, as an LPN entered without a gown, used unclean scissors, changed gloves without hand hygiene, and placed supplies on an unclean nightstand; no isolation cart or EBP sign was present. A second resident with a surgical wound and skin tear also had no EBP sign or isolation cart, and staff entered the room without PPE. The facility also failed to properly complete TB screening for multiple new employees before they worked with residents.
Incomplete CNA In-Service Training: The facility failed to ensure CNAs completed the required annual in-service education, including dementia care and ANE topics. One CNA had only 9.5 documented hours, while two others had no documented training hours; records did not show the required topics or 12-hour minimum were met. Staff interviews described inconsistent training, reliance on computer-based modules, and the DON stated there was no system to ensure CNA training hours were completed.
A resident with depression and intact cognition was ordered Paxil 20 mg daily, but the EHR showed no evidence that the resident was informed of the medication's risks and benefits. The resident stated that no one reviewed the risks involved, and the DON said the physician or nursing staff were responsible for notifying the resident, though it may not have been documented.
A resident with HTN, hyperlipidemia, and age-related physical disability developed significant bilateral foot and ankle edema that was observed over multiple days, with the resident reporting the swelling had been present for a few days and was somewhat painful. The care plan required staff to monitor and document edema and notify the physician, but staff did not recognize or report the swelling until later, when the NP assessed the resident and ordered Lasix, potassium, a chest x-ray, and BNP testing. The DON stated staff should have informed the nurse and that the issue was missed.
Failure to complete CNA performance reviews and regular in-service training
Penalty
Summary
The facility failed to complete a performance review of nurse aides at least once every 12 months and failed to provide regular in-service education for three of five sampled CNAs, identified as CNA C, CNA D, and CNA E. The facility census was 28 residents. The facility's undated In-Service Training, Nurse Aide policy required all personnel to participate in regular in-service education, including annual in-services on continued competence of nurse aides and care of residents with cognitive impairment, and required documentation of nurse aide participation by the DON or designee. The policy also defined supervised practical training and listed acceptable training methods and documentation elements. Review of CNA C's record showed hire on 9/26/24 with no performance review on file or available. CNA D was hired on 5/8/24 and also had no performance review on file or available. CNA E was hired on 9/26/24 and had no performance review on file or available. During interviews, CNA A and CNA B said training was mostly done on a computer program, they were unsure of in-person in-services, and CNA A said he/she had not had a performance review. LPN A stated there had been no skills fairs in the last year and there was not any consistent training offered. The DON said there was no system in place to ensure training hours and performance reviews were completed, it was up to each staff person to make sure training was done, there had been no skills fairs lately, and CNA training was done but not documented. The BOM said the DON tracked training and noted CNA D was PRN and not present when training was offered, while also stating PRN staff should be held to the same training regulations as full-time staff.
Failure to Complete and Track Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure the Medication Regimen Review (MRR) was completed monthly by the contracted pharmacist and reviewed and responded to by the facility physician(s) for three of five sampled residents. The facility policy stated that the licensed pharmacist would complete monthly drug regimen reviews for all residents, the DON or designee would review the MRR and prepare recommendation sheets for the physician, and the DON would document physician response or new orders in the EHR within 14 days of receipt of the monthly pharmacy report. Resident #5 had severe cognitive impairment and diagnoses including thyroid disorder, seizure disorder, and anxiety, with orders for levothyroxine, Keppra, lacosamide, and lorazepam; the pharmacy summary showed no MRR completed in July, August, or September 2025. Resident #21 had moderate cognitive impairment and diagnoses including thyroid disorder, anxiety, and high blood pressure, with orders for levothyroxine, diltiazem, and trazodone; the pharmacy summary showed no MRR completed in July, August, or September 2025. Resident #28 had moderate cognitive impairment and diagnoses including generalized anxiety disorder, major depressive disorder, and deep vein thrombosis, with orders for buspirone, Eliquis, and sertraline; the pharmacy reviews showed no MRR completed in June, July, or August 2025. During interview, the DON stated there had been issues with the MRRs, that a prior PIP had been developed but could not be located, and that the DON was responsible for tracking the MRRs and physician responses. The Administrator stated the MRRs had issues in June, July, and August and expected them to be completed monthly and tracked appropriately.
Unsafe Food Labeling and Storage Practices
Penalty
Summary
Safe food handling and storage were not maintained in the kitchen. During observation of the dry storage unit, multiple food items were found without proper dating or labeling, including a clear plastic container of elbow macaroni with no date, a container of spiral pasta labeled only with "2/8" and no year or other identifiers, and a container of penne pasta with no date opened and a lid that was not securely fastened. An opened box of Cream of Wheat was stored inside a gallon-sized Ziplock bag with no date, and an opened bottle of pure honey also had no date indicating when it was opened. Additional food storage concerns included an opened bag of generic fruit loops with no date and a manufacturer expiration date of 6/2025, an opened bottle of Orange Chicken sauce with no date opened and a manufacturer instruction to refrigerate after opening, and an opened, unsealed bag of corn flakes inside an opened box with no date. During interview, dietary staff stated that opened food containers were supposed to be stickered with the date opened and discarded after seven days, and that unlabeled food should not be served. The Dietary Manager stated that all foods were expected to be labeled with a date-opened sticker, checked for dates before serving, and refrigerated after opening when indicated on the label.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to maintain infection prevention and control practices during wound care for a resident with pulmonary fibrosis and a sacrococcygeal disorder who had a skin tear and nonsurgical dressings documented on the quarterly MDS. During observation of wound care, the LPN entered the room without an isolation gown, placed wound supplies on the resident’s nightstand without first cleaning it or using a barrier, removed soiled gloves and changed into clean gloves without cleansing hands, and used scissors from a pocket without sanitizing them. The LPN also cut the dressing with the scissors without cleansing them. An isolation cart was not present near the room, and there was no EBP sign on the door indicating what PPE should be worn. The same resident was observed on other occasions with no isolation cart in the vicinity of the room and no EBP sign on the door. A housekeeper entered the room without PPE. During interview, the LPN stated that gown and gloves should have been worn, that an isolation cart should have been outside the room, that a sign should have been on the door, and that the scissors should have been bleach wiped before use. The LPN also stated the nightstand should have been bleach wiped or covered with a barrier before wound supplies were placed on it. A second resident with a surgical wound and a skin tear also lacked EBP implementation. Observation showed a housekeeper entering the room without PPE, with no isolation cart nearby and no sign on the door indicating EBP. Another observation showed the same absence of an isolation cart and door sign. A CNA stated the resident had been at the facility for more than a month and that EBP had just started that day. The housekeeper stated the facility had not provided EBP training and that there had not been an EBP sign or isolation cart by the resident’s door, and PPE had not been worn when entering the room to clean.
Incomplete CNA In-Service Training
Penalty
Summary
The facility failed to provide the required 12 hours of annual nurse aide in-service training that included dementia care and abuse, neglect, and exploitation (ANE) topics for three of five sampled CNAs. The facility’s policy required annual in-services for nurse aides, including no less than 12 hours per employment year, training on residents with cognitive impairment, dementia management, and resident abuse/neglect prevention, with documentation of the date, topic, method, summary, and hours completed. Record review showed CNA C completed 9.5 hours of training and had training on Alzheimer’s disease and dementia and on ANE, but did not reach 12 documented hours. CNA D had 0.0 hours of training documented and no in-services attended, with no documentation showing the required topics or hours were met. CNA E also had 0.0 hours of training documented and no documentation showing the required dementia topic, despite attending several in-services and having one undated sign-in sheet. Staff interviews indicated training was inconsistent, much of it was computer-based, and the DON stated he/she was unaware of how many training hours CNAs were required to complete and that there was no system in place to ensure training hours were completed.
Resident Not Informed of Paxil Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the risks and benefits of Paxil when it was ordered by the facility physician to treat depression. Resident #2 was diagnosed with depression, was cognitively intact on the initial MDS, and had an October 2025 physician order for Paxil 20 mg by mouth daily for depression. Review of the resident's EHR showed no evidence that the resident was informed of the risks and/or benefits of Paxil. During interview, the resident stated that medications were received on time and that he/she knew he/she was taking a medication for depression, but could not remember the name. The resident also stated that no one reviewed the risks involved with taking the medication. The DON stated that the resident had the right to be informed, that the physician or nursing staff were responsible for notifying the resident of the risks and benefits, and that the resident was notified but it may not have been documented.
Failure to Timely Address Resident Edema
Penalty
Summary
The facility failed to ensure one resident received appropriate and timely treatment for swollen feet and ankles. The resident had diagnoses including high blood pressure, hyperlipidemia, and age-related physical disability, and the care plan directed staff to monitor and document edema and notify the physician. Resident skin checks were requested but not provided. During observation, the resident was seen sitting in a chair with 3+ bilateral ankle and foot edema, later with feet elevated in a recliner, and then again with 3+ edema and redness in the ankles and feet. The resident stated the swelling had been present for a few days and was somewhat painful, and said staff had told him/her to keep the feet elevated. An LPN later stated he/she had not known about the swollen ankles and would need to notify the physician. A CNA said he/she had helped with cares but had not noticed the swelling and had not received recent education about reporting skin issues. The resident was not noted to have bilateral lower extremity edema until the next day, when the Nurse Practitioner assessed the resident and new orders were obtained for Lasix, potassium, a chest x-ray, and BNP testing. The DON stated staff should have recognized the swollen ankles, informed the nurse, and that the issue was missed.
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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) |
|---|---|---|---|---|
| Butler Rehab And Healthcare Center | 9.9 mi | ★★★★★ | 27 | 0 |
| Medicalodges Butler | 10.1 mi | ★★★★★ | 15 | 0 |
| Meadow View Health & Rehabilitation | 18.1 mi | ★★★★★ | 15 | 0 |
| Crown Rehab And Healthcare Center | 18.3 mi | ★★★★★ | 0 | 0 |
| Golden Years Center For Rehab And Healthcare | 18.9 mi | ★★★★★ | 37 | 3 |
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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.