Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Albany Health Care & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide grooming assistance for a resident who required substantial/maximal help with personal hygiene and was dependent on staff for ADLs. The resident, who had dementia, altered mental status, reduced mobility, and coordination issues, was observed unshaven on multiple occasions. Staff stated residents were generally shaved twice weekly with showers, but one CNA had not shaved or offered to shave the resident that week, and the resident usually needed setup with an electric razor to shave himself.
Failure to Follow Wound Treatment Orders: A resident with DM2, reduced mobility, and an arterial ulcer on the right foot did not receive wound care as ordered. The TAR showed missed treatments and overlapping old and new orders being marked complete, while the UM reported the facility continued daily dressing changes instead of the updated q72h order and left a horseshoe pad in place when it could not be removed, without contacting the wound clinic for further instructions.
Improper Catheter Tubing and Drainage Bag Positioning: A resident with a suprapubic catheter, dementia, and recurrent UTIs was repeatedly observed with catheter tubing coiled on his lap, hanging under his wheelchair, and dragging on the floor while he moved around in his wheelchair. The urinary drainage bag spout was also seen unsecured and hanging onto the floor. Staff acknowledged the tubing should not be on the floor, and the facility policy stated that tubing and the catheter bag should not touch the floor.
Failure to Provide Effective Meal Assistance: A resident with dementia, CVA history, and major weight loss was observed receiving inconsistent meal help, often with staff positioned on her right side despite a care plan directing staff to face her from the front. During multiple meals, she accepted food and fluids better when assistance came from her left side or from family, but staff sometimes offered only a few bites, failed to provide a drink, left meals out of reach, or walked away while she was still eating. The resident’s record showed severe cognitive impairment, partial/moderate assistance needs for eating, and significant unplanned weight loss.
Open and Expired Medications in Cart: During a medication cart observation, multiple items including eye drops, inhalers, laxatives, nasal sprays, and cough medicines were found open and undated in the 100 hall cart, and one bottle of Robitussin DM was expired. RN placed the Robitussin DM in the cart after finding it in a resident's room even though there was no order for it, and staff interviews confirmed opened medications were to be dated and expired items removed.
Improper hand hygiene and bare-hand contact with food occurred during meal tray delivery on the 200 hall. A CNA entered resident rooms, rearranged items on overbed and bedside tables, handled dinner rolls with bare hands, and did not perform hand hygiene during tray distribution. Another CNA delivered trays, assisted with meal setup, touched personal items, poured a drink, and was not observed performing hand hygiene. The IP and DON stated hand hygiene was required before handling meal trays and when entering or exiting resident rooms, and food should not be touched bare handed.
A resident with vascular dementia, impaired mobility, and a documented high fall risk had a care plan and Kardex specifying use of a bed alarm, bed placement against the wall, a low bed with a floor mat, and Dycem non-slip mats in the wheelchair and recliner. Surveyors observed that the resident’s bed was not against the wall, no fall mat was in place, and no non-slip mats were present in the wheelchair or recliner, despite a history of multiple falls including one with a head laceration. Staff interviews confirmed that these interventions were listed in the Kardex but were not in use, and that fall mats were not used on the secured unit even though the care plan had not been revised to reflect this change.
A cognitively impaired male resident with a history of sexually inappropriate behavior was left unsupervised in a lounge area, where he was observed fondling the breast of a non-verbal, dependent female resident. Staff failed to follow care plan interventions requiring increased supervision and separation, resulting in sexual abuse of the female resident.
A resident with severe cognitive impairment was subjected to sexual abuse by another resident, and although staff witnessed and initially reported the incident to a nurse, there was a delay in notifying the Administrator and DON as required by facility policy. The breakdown in communication led to the abuse allegation not being reported immediately, contrary to established procedures.
A resident with dementia and behavioral symptoms was physically restrained by a CNA during a combative episode, resulting in bruising to her wrists and hand. The CNA used a shirt to restrict the resident's arms instead of following behavioral management protocols or seeking assistance. Multiple staff members observed the injuries and heard the resident's allegations but did not immediately report the incident, delaying the initiation of an abuse investigation.
A resident developed bruising on her hands and wrists after alleging that a staff member held her arms. Multiple staff members, including a CNA and an LPN, were informed of the resident's claims and observed her injuries but did not immediately report the alleged abuse to the Administrator as required by facility policy. The delay in reporting was only rectified after the resident's daughter notified an RN, who then informed the DON, leading to an investigation.
The facility failed to deliver mail to residents on Saturdays due to the closure of administrative offices, affecting all 79 residents. Staff interviews revealed confusion about mail distribution responsibilities, with new activity assistants not informed of their duty to deliver mail on weekends. The facility's policy requires mail to be distributed within 24 hours, which was not followed.
A facility failed to submit a new PASRR for a resident who developed new mental health diagnoses and was prescribed psychotropic medications. The resident exhibited significant behavioral changes, including aggression and paranoia, but the required PASRR update was not completed, as confirmed by the Social Services Designee. The facility's policy mandates a new PASRR submission for significant mental status changes, which was not adhered to in this case.
A facility failed to develop and implement a comprehensive care plan for a resident with paraplegia, who expressed concerns about not receiving restorative care or passive range of motion exercises after initial therapy ended. The resident's clinical record lacked a care plan addressing the risk of decreased range of motion or contractures, despite facility policy requiring such plans.
A facility failed to consistently invite a resident's representative to care plan meetings, despite the resident's severe cognitive impairment and preference for family involvement. The representative was only invited once and was unaware of subsequent meetings. The SSD admitted to verbal invitations during visits but lacked documentation, contrary to facility policy.
A resident with limited range of motion did not receive recommended restorative care services after being discharged from physical therapy. Despite requests for care and a discharge recommendation for passive range of motion exercises, the resident was not assigned to receive these services due to a lack of communication and documentation by facility staff. The resident's clinical record lacked a care plan for restorative care, and no services were documented during the assessment period.
A cognitively impaired resident with a history of falls experienced repeated falls and injuries due to inadequate supervision in an LTC facility. Despite interventions like alarms and non-slip mats, the resident continued to fall, indicating insufficient supervision. Staff interviews confirmed a lack of documentation for increased supervision, highlighting a deficiency in care.
A resident with Alzheimer's and dysphagia experienced significant weight loss, but the facility failed to notify the physician as required. Despite alerts from the facility's software, staff were unaware of the weight loss, and the resident was not on the Nutritional At Risk list. The DON confirmed the physician should have been informed according to policy.
The facility did not ensure that the most recent IDOH survey reports were accessible to residents. During a Resident Council interview, residents were unaware of the survey report location. An observation found the report binder near the Human Resources office, but it contained outdated information and lacked recent survey reports and plans of correction. Interviews revealed confusion over responsibility for maintaining the binder, contrary to the facility's policy requiring up-to-date survey documentation.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide grooming assistance for one resident who was unable to complete the task independently. The resident had diagnoses including altered mental status, dementia, other lack of coordination, other reduced mobility, and need for assistance with personal care. A quarterly MDS assessment dated 1/19/26 indicated the resident was severely cognitively impaired and required substantial/maximal staff assistance with personal hygiene. The care plan indicated he needed assistance with ADLs related to activity intolerance and was dependent on staff for morning and evening care. During observations on 2/16/26, 2/17/26, 2/18/26, and 2/19/26, the resident was seen in a wheelchair in the dining room or his room and was unshaven each time. The resident had received a shower on 2/11/26 and bed baths on 2/15/26 and 2/18/26, and staff stated residents were generally shaved twice weekly with showers. Interviews showed CNA 8 had not shaved or offered to shave the resident that week, CNA 6 stated residents were shaved on shower days and as needed, and CNA 5 said she had set up the resident with his electric razor to shave and that he usually shaved himself with setup. The DON stated residents should be shaved at least twice a week on shower days, while the facility procedure for electric razors did not specify when or how often shaving should occur.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility failed to follow physician wound treatment orders for a resident with heart failure, type 2 diabetes mellitus, reduced mobility, and an arterial ulcer on the right foot. The resident was cognitively intact and required maximal staff assistance with lower body dressing, repositioning, and footwear, and was dependent on staff for transfers. A wound treatment order for the right dorsum foot required cleansing with povidone iodine, air drying, skin preparation, and a foam dressing every day, and a later wound clinic order required a horseshoe pad to the right medial foot, Betadine, alginate between the toes, and coverage with an ABD pad, soft roll, rolled gauze, and stretch net changed three times weekly every 72 hours. The Treatment Administration Record showed multiple instances where wound treatments were not completed and also showed both the old and new wound treatment orders being marked completed on the same days. During observation, the resident had a dressing on the right foot. The Unit Manager stated the facility had received the new order to change the dressing every three days but did not catch the duplicate order until the dressing change on 2/18/26, and that the facility appeared to have continued daily dressing changes rather than following the new order. She also stated that on 2/18/26 she was unable to remove the horseshoe pad, cleansed around it, left it in place, and did not contact the wound clinic for further instructions. The DON stated staff should always follow physician orders, previous wound care orders should have been discontinued when new orders were received, and the provider must be notified when wound care cannot be completed according to the order.
Improper Catheter Tubing and Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure appropriate catheter maintenance and services to prevent potential urinary tract infections for a resident with an indwelling suprapubic catheter. Resident 16 had diagnoses including BPH with urinary retention, neuromuscular dysfunction of the bladder, altered mental status, dementia, and need for assistance with personal care. The resident’s record showed orders for a suprapubic catheter, daily and evening irrigation, catheter site care every shift, and enhanced barrier precautions, and the care plan identified chronic and recurring UTIs and a suprapubic catheter related to neurogenic bladder. During multiple observations, the resident’s catheter tubing was seen hanging from his waistband and wheelchair area, coiled on his lap, resting on the floor, and dragging on the floor as he propelled himself in his wheelchair. The tubing was also observed under the wheelchair, within a pencil eraser’s diameter of the floor, and later twisted around the resident’s left front wheelchair wheel after his heel rested on it. The resident was observed in the dining room and in his room with the tubing repeatedly contacting or dragging on the floor. The urinary drainage bag spout was also observed unsecured and hanging from the privacy bag onto the floor. The DON later secured the drainage spout so it no longer dragged on the floor. Staff interviews indicated the tubing should not be on the floor and that it was sometimes clipped to the resident’s clothing, but because the resident was very mobile in his wheelchair, the tubing was sometimes found on the floor. The facility policy stated that tubing and the catheter bag should not touch the floor.
Failure to Provide Effective Meal Assistance
Penalty
Summary
The facility failed to provide meal assistance to maintain the nutritional status of one resident who had dementia, age-related physical debility, cerebral infarction, cognitive communication deficit, and needed assistance with personal care. The resident’s record showed severe cognitive impairment, partial/moderate assistance needed for eating and oral hygiene, and significant weight loss, including a drop from 134 pounds on 08/05/2025 to 93.6 pounds on 2/8/26, a 30.15% loss. Her care plan identified her as at risk for malnutrition and directed staff to assist with eating, review meal intake and weights, and provide extra food or beverages with meals or between meals. During dining observations, the resident’s meal assistance was inconsistent and often ineffective when staff positioned themselves on her right side. On 2/18/26, the resident accepted only one bite from her visitor while the visitor sat on the resident’s right side, but after the visitor moved to the resident’s left side, the resident consistently accepted every bite offered. On 2/19/26 at breakfast, a staff member sat on the resident’s right side while her neck was bent forward and her head was hanging down; the resident did not accept additional bites, and the staff member later walked away to chart. The resident then allowed food and fluids to fall from her mouth before staff approached from the left side and removed her from the dining room. At lunch the same day, the resident’s tray was placed in front of her with ice cream and a supplement, but no drink was provided. A staff member sat on the resident’s right side, did not acknowledge her at first, and attempted to reach around her to offer bites of food; only two bites were offered over the observation period before the resident’s visitor arrived and took over meal assistance. When the visitor moved to the resident’s left side, the resident accepted food and fluids, including soda from a straw, and continued eating. Later that afternoon, the resident’s meal was left out of reach while she lay in bed, and no bites of food or fluids were offered during the observation. When staff later returned, the resident’s supper remained largely untouched, and no food was offered until soup was warmed; the resident stated she was hungry and drank from a cup when it was handed to her, but no bites of food were offered during that observation.
Open and Expired Medications in Cart
Penalty
Summary
The facility failed to ensure medications were dated when opened and that expired medications were removed from storage for 1 of 3 medication carts reviewed, the 100 hall medication cart. During observation of the cart with QMA 10, six bottles of eye drops, two metered dose inhalers, one bottle of Robitussin DM, one bottle of Black Seed herbal supplement, nine bottles of Miralax, two bottles of liquid Docusate Sodium, one bottle of cough medication liquid, one bottle of Lactulose, five bottles of Milk of Magnesia, one bottle of saline nasal spray, and two bottles of Flonase nasal spray were observed open and undated. One bottle of Robitussin DM was also observed with an expiration date of 9/2024. During interview, QMA 10 stated he was unsure whether opened items needed to be labeled and dated when opened and believed the facility used product expiration dates. RN 12 stated he had found the Robitussin DM in a resident's room, removed it, and placed it in the medication cart even though the resident did not have an order for it and he did not notify the physician or request an order. LPN 11 stated all medications were to be labeled with an open date, all medications in the cart were to have a physician order, and expired items were to be removed. The DON also stated medications were to be dated when opened, have a physician order, and there were not to be any expired medications in the medication cart.
Improper Hand Hygiene and Bare-Hand Contact With Food During Tray Delivery
Penalty
Summary
The facility failed to utilize proper hand hygiene and avoid touching food with bare hands during meal tray distribution on the 200 hall. During an observation on 2/16/26 at 12:11 p.m., CNA 8 entered room [ROOM NUMBER]-D with a meal tray, rearranged a book and cup on the overbed table before setting up the tray, and did not perform hand hygiene. CNA 8 then removed the dinner roll bare handed and placed it on top of the wrap it came in. Later that day at 12:19 p.m., CNA 8 entered room [ROOM NUMBER]-W with a meal tray, took the dinner roll out of a plastic bag with her bare hands, and placed it in front of the resident. During interview, CNA 8 stated she probably should have washed her hands before touching residents’ food and said she used hand sanitizer after handing out lunch trays to avoid cross contamination. During an observation on 2/19/26 at 4:56 p.m., CNA 9 retrieved a meal tray from the cart and delivered it to room [ROOM NUMBER]-D, assisted the resident with meal set up, and touched personal items on the bedside table. She then exited the room, poured a yellow drink from the drink cart, placed the cup on a tray in the food cart, and delivered another meal tray to room [ROOM NUMBER]-D. Hand hygiene was not observed at any time during the observation. During interview, CNA 9 stated she probably should have performed hand hygiene after she passed out each tray and said hand hygiene was done to prevent cross contamination. The Infection Preventionist stated hand hygiene was required before picking up any meal trays, and the DON stated hand hygiene must be completed every time staff enter and exit resident rooms, after touching themselves, and after touching objects; the DON also stated food should not be touched bare handed. A current policy titled Hand Antiseptic for Food Service stated hand antiseptic or antimicrobial gel used by staff as a hand dip or wash would be limited to situations that involve no direct contact with food by the bare hands.
Failure to Implement Care-Planned Fall Prevention Interventions
Penalty
Summary
Surveyors identified a failure to implement care-planned fall prevention interventions for a resident with multiple risk factors and a history of falls. The resident had diagnoses including age-related physical disability, syncope and collapse, difficulty walking, and vascular dementia, and was assessed as severely cognitively impaired and at high risk for falls on multiple fall risk assessments. Her care plan, initiated for fall risk related to impaired balance, included use of a bed alarm to remind staff she required assistance with bed mobility and transfers, placement of her bed against the wall per her preference, Dycem (non-slip material) in her recliner and wheelchair to prevent sliding, and use of a low bed with a floor mat to decrease injury risk when rolling out of bed. The Kardex also reflected these interventions. Despite these documented interventions, observations on multiple occasions showed that the resident’s room setup and equipment did not match the care plan. On two separate dining room observations, the resident was seen in a wheelchair wearing nonskid socks and a brace on her right foot/leg, but when her room was observed, her bed was not against the wall, there was no non-slip mat in the recliner or wheelchair, and no fall mat was visible. Another observation found the resident lying in a low bed without a mat beside it, with the bed still not against the wall and no non-slip mats present in the wheelchair or recliner. These discrepancies occurred after the resident had experienced multiple documented falls, including falls on several dates, one of which resulted in a laceration with bleeding to her right eyebrow. Staff interviews confirmed that the care-planned fall interventions were not being implemented as written. CNA staff stated that fall interventions were listed on the electronic Kardex and identified a bed alarm, increased supervision, and toileting assistance as the resident’s fall interventions, but acknowledged that the bed was not against the wall, there was no fall mat in use on the secured unit, and the non-slip mat was not present in the room, wheelchair, or recliner. The unit manager reported that fall mats were not utilized on the secured unit because they were considered a fall risk for wandering residents and that the resident’s care plan had not yet been revised after her move back to the secured unit. The DON similarly stated that the care plan should have been updated and that interventions such as the bed against the wall and non-slip mats in the wheelchair and recliner should have been in place, while also confirming that fall mats were not used on the secured unit due to being considered a trip hazard. The facility’s fall policy defined avoidable accidents as those occurring when the facility failed to implement interventions, including adequate supervision and assistive devices.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
A cognitively impaired male resident with a documented history of sexually inappropriate behaviors was observed inappropriately touching a cognitively impaired, non-verbal female resident in a lounge area. The male resident had prior incidents of sexually charged behavior, including attempts to touch female residents and staff inappropriately, and was known to be able to move himself in his wheelchair despite staff attempts to position him in a recliner for safety. On the day of the incident, staff left the male resident in his wheelchair in the lounge with female residents present, contrary to his care plan interventions, which included increased supervision and physical separation from female residents due to his behavioral history. The female resident involved was non-verbal, severely cognitively impaired, and fully dependent on staff for all activities of daily living, making her unable to defend herself or communicate consent. Staff observed the male resident with his hand inside the female resident's shirt, fondling her breast. The incident occurred when a CNA left the male resident unattended in his wheelchair near the female resident while assisting another resident, despite being aware of his history of inappropriate sexual behavior. The nurse on duty was not immediately informed of the incident, and there was a delay in reporting to facility leadership. The facility's policy required the prevention of abuse and the deployment of sufficient, trained staff to meet residents' needs and prevent abuse. Despite this, the male resident's known behaviors were not adequately managed, and staff failed to follow established interventions, resulting in the female resident being subjected to sexual abuse. The incident was witnessed by staff, and subsequent interviews confirmed that staff were aware of the male resident's behavioral risks but did not consistently implement the required precautions.
Failure to Immediately Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving a resident with severe cognitive impairment. Staff observed one resident touching another resident's breast in a common area. Although the incident was witnessed and initially reported by a CNA to an RN, the RN did not immediately notify the Administrator, DON, or other required personnel. The incident occurred after dinner, but the Administrator and DON were not informed until over two hours later, despite facility policy requiring immediate reporting of abuse allegations. Interviews revealed that staff were aware of the requirement to report abuse immediately to supervisory staff, including the Administrator and DON, and had the means to do so after hours. However, there was a breakdown in communication, as the initial report was not escalated promptly. The facility's policy, which mandates reporting of all alleged violations to the Administrator within two hours, was not followed in this case, resulting in a delay in the notification and investigation of the alleged abuse.
Failure to Protect Resident from Staff-to-Resident Abuse
Penalty
Summary
A cognitively impaired resident with a history of dementia, behavioral symptoms, and the need for substantial assistance with personal care was subjected to staff-to-resident abuse. The incident occurred when a CNA, working alone with the resident during the night shift, responded to the resident's combative behavior by physically restraining her arms using a shirt. This action resulted in dark purple bruises on the resident's bilateral wrists and left hand. The resident later reported the incident to her daughter, describing the staff member's actions and identifying her by physical characteristics. Multiple staff members observed the bruising and heard the resident's allegations, but failed to immediately report the incident as required. The clinical record indicated that the resident was at higher risk for abuse due to her behavioral symptoms, including verbal and physical aggression, and her need for assistance with mobility and personal care. Despite these known risks, the staff member involved did not seek assistance from other staff when the resident became combative, nor did she follow established protocols for managing challenging behaviors. Instead, she attempted to restrain the resident, which is considered abusive according to facility policy. The resident's care plan included interventions for behavioral symptoms, but these were not followed during the incident. Additionally, several staff members, including CNAs and an LPN, became aware of the resident's allegations and observed the resulting injuries but did not immediately report the situation to facility leadership or initiate an investigation. This delay in reporting further compromised the resident's safety and failed to ensure timely protection from abuse. The facility's policy clearly states that any suspicion or allegation of abuse must be reported and investigated immediately, and that staff retaliation or inappropriate handling of resident behaviors constitutes abuse.
Failure to Immediately Report Alleged Abuse and Resident Injuries
Penalty
Summary
The facility failed to identify and immediately report an allegation of abuse involving a resident who developed bruising on her hands and wrists, reportedly as a result of a staff member holding her arms. The resident communicated the alleged abuse to several staff members, including a CNA and an LPN, during the night shift. Despite being informed, these staff members did not immediately notify the Administrator or management about the allegation. The CNA reported the resident's accusation to the LPN, who also failed to escalate the concern. Other staff members observed the bruising and heard the resident's allegations but did not report them promptly. The delay in reporting was further evidenced by interviews with staff, where it was revealed that multiple employees were aware of the resident's claims and visible injuries but did not follow the facility's policy to report such incidents immediately to the Administrator. The Director of Nursing (DON) only became aware of the situation after being notified by an RN, who had been informed by the resident's daughter. The DON then initiated the investigation and notified the Administrator, but this was not done until several hours after the initial allegations were made and observed by staff. The facility's policy required that all allegations of mistreatment, neglect, or abuse, including injuries of unknown source, be reported immediately to the Administrator and other officials as required by law. In this case, the failure of multiple staff members to report the resident's allegations and observed injuries in a timely manner constituted a breach of this policy and resulted in a deficiency related to the prompt reporting of suspected abuse.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that mail was distributed to residents on Saturdays, affecting all 79 residents. During a Resident Council group interview, several residents reported not receiving mail on Saturdays due to the administrative offices being closed on weekends. Interviews with various staff members, including a QMA, CNA, and the Dementia Care Director, confirmed that mail was not delivered to residents on Saturdays because it was sent to the business office, which was closed. The Activity Director revealed that the activity assistants had not been delivering mail on Saturdays until recently, as they believed the business office was responsible for sorting and distributing mail. The Administrator acknowledged that new activity assistants were not informed about their responsibility to collect and deliver mail on Saturdays. The facility's policy, revised in 2017, mandates that mail be distributed to residents within 24 hours of delivery by the postal service, which was not adhered to in this case.
Failure to Submit PASRR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis and psychotropic medication. The resident, identified as Resident 59, had a PASRR completed on 6/20/23, which indicated no known or suspected mental health diagnoses and no mental health medications. However, the resident's diagnoses included psychotic disorder with delusions, unspecified mood disorder, generalized anxiety disorder, other recurrent depressive disorders, and dementia with agitation. The resident was prescribed escitalopram oxalate, an antidepressant, and olanzapine, an antipsychotic, with changes in dosages over time. The resident exhibited behavioral symptoms such as agitation, aggression, and paranoia, which were documented in the care plan and nurse's notes. Despite these changes, a new PASRR was not submitted, as confirmed by the Social Services Designee responsible for PASRR submissions. The facility's policy and the Indiana PASRR Level I & Level of Care Screening Procedures require a new Level I PASRR to be submitted when there is a significant change in a resident's mental status, such as a new mental health diagnosis or the introduction of psychotropic medication. This oversight led to the deficiency identified in the report.
Failure to Implement Comprehensive Care Plan for Resident with Paraplegia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with individualized interventions for a resident with limited range of motion due to paraplegia. During an interview, the resident expressed concerns about not receiving restorative care or passive range of motion exercises after his initial therapy ended. He had requested restorative care from therapy staff but had not received any, raising concerns about losing the progress made during therapy. A review of the resident's clinical record revealed diagnoses including paralytic syndrome, complete paraplegia, and generalized muscle weakness, but lacked a care plan addressing the risk of decreased range of motion or development of contractures. The MDS Coordinator confirmed that a care plan for restorative care should have been developed but was not present in the resident's record. The facility's policy requires a comprehensive person-centered care plan with measurable objectives and timeframes, which was not adhered to in this case.
Failure to Involve Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure that the representative of a resident, who was severely cognitively impaired and had conditions such as anxiety disorder, delusional disorder, Alzheimer's disease, and unspecified dementia with agitation, was consistently invited to participate in the ongoing care planning process. The resident's representative reported being invited to only one care plan meeting and was unaware of when subsequent meetings were held. The resident's clinical record indicated a preference for family involvement in care discussions, yet there was a lack of documentation showing recent attempts to invite the representative to care plan conferences. The Social Services Designee (SSD) acknowledged that invitations for care plan meetings were typically extended by phone for short-term residents and by mail for long-term residents. However, there was no documentation in the progress notes confirming that the resident's representative had been invited to recent care plan meetings. Despite verbal invitations being extended during the representative's frequent visits, these were not documented. The facility's policy required documentation of invitations, but this was not adhered to, leading to the deficiency.
Failure to Provide Restorative Care Services
Penalty
Summary
The facility failed to provide appropriate restorative care services for a resident with limited range of motion, identified as Resident 73. The resident, who is paralyzed from the chest down, had previously received therapy upon admission but was waiting for insurance approval for further therapy. During this waiting period, the resident did not receive any restorative care or passive range of motion exercises for his lower extremities, despite having requested such care from therapy staff. The resident expressed concern about losing the progress made during therapy. The clinical record review revealed that Resident 73 was admitted with diagnoses including paralytic syndrome, complete paraplegia, and generalized muscle weakness. The resident's medication orders included treatments for muscle spasms and constipation. A Physical Therapy Discharge Summary recommended the resident for a Restorative Nursing Program, specifically for passive range of motion exercises, but these recommendations were not implemented. The resident's clinical record lacked a care plan for restorative care, and no restorative services were documented during the assessment period. Interviews with facility staff, including restorative aides, the physical therapist, the rehabilitation director, and the MDS coordinator, confirmed that the resident was not assigned to receive restorative care. The previous MDS Coordinator, who was responsible for assigning residents to restorative aides, did not initiate the therapy recommendations. The current MDS Coordinator was unaware of the resident's need for restorative care due to a lack of documentation and communication from the previous coordinator. The facility's policy on restorative nursing was not followed, resulting in the resident not receiving necessary services to maintain or improve range of motion.
Inadequate Supervision Leads to Repeated Falls for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident with a history of falls, leading to repeated falls and injuries. The resident, identified as having severe cognitive impairment, hallucinations, and a history of falls, was observed in various states of activity and rest, often with a bed or chair alarm in place. Despite these measures, the resident experienced multiple falls, including one that resulted in a laceration to the forehead and a fracture in the wrist. The resident's care plan included interventions such as the use of alarms, non-slip mats, and regular toileting, but these measures were insufficient to prevent further falls. The resident's clinical record indicated a high risk for falls due to multiple factors, including syncope, muscle weakness, and a history of falling. The resident was on medications that increased the risk of falling and had several predisposing conditions. Despite the presence of alarms and other interventions, the resident continued to fall, sometimes in the presence of staff, indicating a lack of effective supervision. The facility's policy required the environment to be free of accident hazards and for residents to receive adequate supervision, but this was not achieved in the case of this resident. Interviews with staff revealed that while various interventions were in place, there was no documentation of increased supervision or additional measures to ensure the resident's safety. The Director of Nursing acknowledged that pressure alarms should not replace supervision, yet there was no evidence of enhanced supervision being implemented. The facility's failure to adequately supervise the resident and prevent repeated falls constitutes a deficiency in care.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident, identified as Resident 72, who was under review for nutrition. The resident had a history of Alzheimer's disease, dysphagia, and depressive disorders, and was on a specific diet with supplements. The resident's weight records showed a notable decrease over several months, with an 8.69% weight loss in one week and a 10.24% loss over nearly six months. Despite these changes, there was no documentation of physician or resident representative notification regarding the weight loss. Interviews with facility staff revealed a breakdown in communication and procedure adherence. LPN 17, the charge nurse, was unaware of the weight loss and assumed the aides had informed the Nutritional At Risk (NAR) team. However, RN 18, the unit manager and part of the NAR team, confirmed the resident was not on the NAR list and was unaware of the weight loss. The facility's software had triggered an alert for the weight loss, but there was no evidence of physician notification. The Director of Nursing (DON) acknowledged that the physician should have been informed, as per the facility's policy on notifying changes in a resident's condition.
Failure to Maintain Accessible Survey Reports
Penalty
Summary
The facility failed to ensure that the most recent Indiana Department of Health (IDOH) survey reports were readily available for review by residents. During a Resident Council group interview, several residents indicated they were unaware of the location of the State Department of Health survey reports. An observation revealed that the survey report was located in a binder placed in a wall pocket beside the Human Resources office, but the most recent survey in the binder was from the Annual Recertification and State Licensure Survey completed on January 22, 2024, and it lacked the plan of correction. Additionally, the facility's IDOH survey history indicated that Complaint Investigation Surveys were completed on May 3, 2024, September 13, 2024, and October 18, 2024, but these were not included in the binder. Interviews with the Human Resources Director and the Administrator revealed a lack of clarity and responsibility regarding the maintenance of the survey report binder. The Human Resources Director believed the Administrator was responsible for maintaining the binder, while the Administrator acknowledged his responsibility but was uncertain about the whereabouts of the printed survey reports for the past year. The facility's policy, dated November 1, 2023, required that a readable copy of the most recent federal and/or state survey report and plan of correction be maintained in a 3-ring binder, along with reports of any surveys, certifications, and complaint investigations from the preceding three years. This policy was not adhered to, resulting in the deficiency.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 246 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Dunkirk Skilled Nursing Facility, The | 6.8 mi | ★★★★★ | 3 | 1 |
| Envive Of Muncie | 8 mi | ★★★★★ | 12 | 0 |
| Parker Health Care & Rehabilitation Center | 8.2 mi | ★★★★★ | 10 | 0 |
| Cardinal Care Strategies | 8.7 mi | ★★★★★ | 30 | 3 |
| Signature Healthcare Of Muncie | 9 mi | ★★★★★ | 30 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.