Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Adams Farm Living & Rehabilitation during CMS and state inspections, most recent first.
A nurse aide failed to don a gown while providing oral care to a resident on Enhanced Barrier Precautions (EBP) for wounds and an indwelling catheter, despite clear signage and prior training. The aide wore only a mask and gloves during the high contact care activity, contrary to facility policy requiring both gown and gloves for such procedures. Facility leadership confirmed that staff are expected to follow EBP protocols during hands-on care.
A resident with a history of seizures and multiple comorbidities had their seizure medication discontinued without notification to their Responsible Party (RP). The nurse entered a verbal order to stop the medication, but there was no documentation of who gave the order, and the RP was not informed. The resident later experienced a seizure and was hospitalized, with the RP only learning of the medication change after the hospitalization. The resident's physician was also unaware of the discontinuation until after the event.
A resident with a history of encephalopathy and seizure-like activity was discharged from the hospital with orders to continue Keppra and follow up with neurology. The facility did not arrange the neurology consult, and Keppra was later discontinued via a verbal order without clear documentation or provider confirmation. The resident subsequently experienced a seizure and required hospitalization, with hospital staff noting the absence of Keppra as a likely cause.
A resident with a history of seizures and recent hospital discharge for neurological issues did not receive a required neurology follow-up, and her seizure medication was discontinued without proper review or documentation by multiple providers. The lack of coordination and oversight resulted in the resident experiencing a seizure and requiring ICU hospitalization.
A consultant pharmacist did not report to the attending physician when a resident who was started on Keppra for a new neurological disorder did not receive a recommended neurology consult. The pharmacist noted the need for neurology follow-up in monthly reviews but did not address or report the missed consult or clarify a discrepancy when Keppra was discontinued without documented rationale, and the physician later listed it as active.
A resident's medical record lacked documentation of the rationale and provider for a verbal order to discontinue Keppra, a seizure medication. Additionally, a physician's progress note inaccurately listed Keppra as active after it had been discontinued. The failures resulted in incomplete and inaccurate medical records.
The facility failed to maintain cleanliness in the kitchen and did not properly label perishable food items, potentially affecting food quality. Observations showed soiled ovens and unlabeled food in the refrigerator. Staff interviews revealed a lack of cleaning logs and unclear responsibility for food labeling and expiration checks.
The facility failed to label medications not stored in original packaging, as observed in the 400 and 500 hall medication carts. Loose pills were found in the 400-hall cart, and unlabeled pills were in a bag in the 500-hall cart. Nurses and medication aides were responsible for ensuring proper labeling and organization, as confirmed by the DON.
Failure to Follow Enhanced Barrier Precautions During Oral Care
Penalty
Summary
Nurse Aide #3 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing oral care to Resident #2, who was under EBP due to wounds and an indwelling catheter. During an observation, NA #3 entered the resident's room, draped a blanket over the resident, and began providing oral care while wearing only a mask and gloves, omitting the required gown. The EBP signage was clearly posted outside the room, indicating the need for gown and gloves during high contact care activities such as providing hygiene. NA #3 acknowledged awareness of the policy and attributed the lapse to rushing, despite having received training on EBP procedures. Resident #2 was in a semi-private room, and both occupants were on EBP. The facility's policy, dated 5/13/2023, specified that gown and gloves must be used for high contact care activities for residents with wounds or indwelling medical devices. Interviews with the DON and Administrator confirmed that staff were expected to don appropriate PPE, including gowns and gloves, when performing hands-on care for residents on EBP. The deficiency was identified during direct observation and confirmed through staff interviews, highlighting a failure to implement the facility's infection control policy during a high contact care activity.
Failure to Notify Responsible Party of Seizure Medication Discontinuation
Penalty
Summary
The facility failed to notify a resident's Responsible Party (RP) when the resident's seizure medication, Levetiracetam (Keppra), was discontinued. The resident, who had a complex medical history including chronic obstructive pulmonary disease, chronic respiratory failure, ischemic heart disease, prior strokes, and a history of seizures, was initially admitted with orders for Keppra following a hospitalization for seizures and metabolic encephalopathy. The hospital physician had recommended that any decision to discontinue Keppra should be made after a neurology consult, but no such consult was ordered or initiated after the resident's return to the facility. On a later date, a verbal order was entered by a nurse to discontinue Keppra, but there was no documentation of who gave the order, and the RP was not notified of this significant medication change. Interviews revealed that the nurse believed the order was given by a nurse practitioner (NP), but the NP did not recall giving the order and confirmed that she had not discussed discontinuing Keppra with the RP. The resident subsequently experienced another seizure, was hospitalized, and the RP only learned of the medication discontinuation after the resident was admitted to the hospital. The resident's physician was also unaware of the medication discontinuation until after the resident's hospitalization. Documentation in the facility records confirmed that the RP was not notified at the time of the medication change, and the lack of communication prevented the RP from advocating for the resident, as she would have informed the facility that discontinuation should not occur without a neurologist's evaluation. The failure to notify the RP of the medication discontinuation directly contributed to the resident's subsequent seizure and hospitalization.
Failure to Arrange Neurology Follow-Up and Ensure Proper Medication Management
Penalty
Summary
A resident with a complex medical history, including chronic obstructive pulmonary disease, chronic respiratory failure, ischemic heart disease, prior strokes, and a recent episode of encephalopathy with seizure-like activity, was discharged from the hospital with orders to continue Keppra (an anticonvulsant) and to follow up with neurology. The hospital discharge summary specifically noted the need for a neurology consult to determine the long-term plan for Keppra therapy. Upon readmission to the facility, the Keppra order was initiated, but no neurology consult was arranged as directed in the discharge plan. Multiple providers, including nurse practitioners and physicians, were involved in the resident's care following readmission. Documentation shows that the need for neurology follow-up was not addressed in provider notes, and staff interviews revealed confusion or lack of awareness regarding the consult recommendation. In February, a verbal order to discontinue Keppra was entered by a nurse, but there was no documentation of which provider gave the order or the rationale for discontinuation. Interviews with the nurse practitioner and physician involved revealed that neither recalled giving or authorizing the discontinuation, and the responsible party was not notified of the medication change. Subsequently, the resident experienced a seizure requiring emergency intervention and hospitalization. Hospital records and interviews indicated that the resident had not been receiving Keppra at the time of the event, and the hospital neurologist attributed the seizure to the absence of antiepileptic medication. The facility's failure to arrange the neurology consult and to ensure proper documentation and communication regarding the discontinuation of Keppra directly contributed to the resident not receiving appropriate follow-up and medication management as ordered.
Failure to Ensure Provider Review of Care Plan and Medication Orders
Penalty
Summary
The facility failed to ensure that the resident’s care plan was thoroughly reviewed and followed by all providers during and after a change in primary care providers, resulting in a missed neurology follow-up and inappropriate discontinuation of seizure medication. A resident with a complex medical history, including chronic obstructive pulmonary disease, ischemic heart disease, history of stroke, and a recent diagnosis of seizure activity, was discharged from the hospital with instructions to continue Keppra and to follow up with neurology. The hospital discharge summary specifically recommended an outpatient neurology appointment to determine the long-term plan for seizure management, and the medication Keppra was ordered to continue upon admission to the facility. Despite these clear instructions, no neurology consult was ordered or initiated after the resident’s admission. Multiple providers, including nurse practitioners and physicians, saw the resident during routine and regulatory visits but failed to recognize or act on the need for a neurology follow-up. Progress notes from these visits did not mention the missed neurology appointment, and providers reported in interviews that they were unaware of the hospital’s recommendation. Additionally, there was a change in the primary provider team, and the new team did not identify the need for neurology follow-up or review the full plan of care as outlined in the hospital discharge summary. On a later date, a verbal order to discontinue Keppra was entered into the resident’s record without clear documentation of who gave the order or the clinical reasoning behind it. The physician’s electronic signature appeared on the order, but both the nurse practitioner and physician interviewed did not recall authorizing the discontinuation. The resident’s medication administration record showed that Keppra was stopped, and subsequent physician progress notes incorrectly listed Keppra as an active medication. The lack of coordination and communication among providers led to the resident experiencing a seizure and requiring hospitalization in the intensive care unit.
Consultant Pharmacist Failed to Report Missed Neurology Consult and Medication Discrepancy
Penalty
Summary
The Consultant Pharmacist failed to report to the attending physician when a resident's record showed that a recommended neurology consult was never obtained after the resident experienced a newly diagnosed neurological disorder and was started on Keppra during a hospital stay. The hospital discharge summary specifically instructed that neurology should be involved in the continued plan for Keppra, and an appointment was requested for follow-up. Upon admission to the facility, Keppra was ordered, but no neurology consultation was initiated or ordered. The Consultant Pharmacist noted the need to 'follow for neuro' in monthly reviews but did not address the absence of the neurology consult or report this irregularity to the physician as required by facility policy and procedures. Additionally, Keppra was discontinued by verbal order with no documented reason, and the neurology consult still had not been completed at the time of discontinuation. The physician later documented Keppra as an active medication in a progress note, despite having signed the discontinuation order. The Consultant Pharmacist did not seek clarification from the physician regarding this discrepancy or the lack of neurology follow-up. Interviews with the Consultant Pharmacist and the Pharmacy Director of Clinical Services confirmed that the pharmacist did not question the rationale for discontinuation or the absence of the neurology consult, failing to follow irregularity reporting guidelines.
Incomplete and Inaccurate Documentation of Seizure Medication Discontinuation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident regarding the discontinuation of a seizure medication, Keppra. On 2/12/25, a nurse entered a verbal order to discontinue Keppra in the resident's record, but did not document which provider gave the order or the rationale for discontinuation. The nurse later stated that a nurse practitioner had provided the verbal order due to the absence of a definite epilepsy diagnosis and a therapeutic Keppra level, but this reasoning was not recorded in the resident's chart. Additionally, a physician's progress note dated 2/24/25 inaccurately listed Keppra as an active medication, despite the medication having been discontinued earlier. The physician confirmed that the rationale for discontinuation should have been documented by the provider or the nurse who received the order.
Kitchen Cleanliness and Food Labeling Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen, which could potentially affect the quality of food served to residents. Observations revealed that both the top and bottom ovens were heavily soiled with burnt food stains and debris, indicating they had not been cleaned as required. Interviews with the Dietary Manager in training and the Cook confirmed that there was no log of when the ovens were last cleaned, and the staff could not recall the last cleaning. The Corporate Regional Manager for Dietary acknowledged awareness of the cleanliness issues and stated that the ovens appeared to have not been cleaned for more than a week. Additionally, the facility did not label and date perishable food items in the walk-in refrigerator, which included cheese slices, chopped garlic, beef flavored base, sour cream, lettuce and tomatoes, cherries, and raw eggs. The Dietary Manager in training admitted that there was no specific staff member assigned to check for labeling and expiration dates, and any staff could perform this task. The Administrator and the new Dietary Manager were informed of these findings, but there was no clear assignment of responsibility for ensuring proper labeling and discarding of expired food items.
Medication Labeling Deficiency in Medication Carts
Penalty
Summary
The facility failed to properly label medications that were not stored in their original pharmacy or manufacturer packaging, as observed during a review of the medication carts on the 400 and 500 halls. On the 400-hall medication cart, four loose pills of various shapes, colors, and sizes were found at the bottom of the cart drawers. Nurse #4 stated that each nurse assigned to the medication cart was responsible for cleaning, organizing, and ensuring the cart was well-stocked. The Director of Nursing (DON) confirmed that nurses on duty were expected to clean and organize the medication carts and discard any loose pills. On the 500-hall medication cart, three white pills were found in an unlabeled clear white bag, lacking any medication name, resident name, or dosage instructions. Medication Aide (MA) #3 admitted to placing the pills in the bag, while Nurse #5 indicated that each nurse was responsible for ensuring medications were labeled. The DON stated that nurses oversee medication aides and emphasized that medications must be used from labeled containers and administered immediately after removal from the original container, as per physician orders.
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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 Jamestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Camden Health And Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| The Shannon Gray Rehabilitation & Recovery Center | 3.5 mi | ★★★★★ | 1 | 0 |
| Maryfield Nursing Home | 3.8 mi | ★★★★★ | 1 | 0 |
| Whitestone A Masonic And Eastern Star Community | 4.4 mi | ★★★★★ | 0 | 0 |
| Greenhaven Health And Rehabilitation Center | 4.7 mi | ★★★★★ | 2 | 2 |
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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.