Below average — CMS composite of the measures below.
The next survey window likely opens 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 Albemarle Health & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with dementia and exit-seeking behaviors were not properly supervised or reassessed for elopement risk after repeated incidents, including one resident who eloped from the facility undetected. Staff failed to follow established protocols for missing residents, did not update risk assessments, and did not ensure wander guard devices were secure or that resident information was available in the elopement binder. These failures resulted in serious lapses in resident safety and noncompliance with accident prevention requirements.
Failure to Resolve Resident Council Grievances: A resident council repeatedly raised concerns about sticky, dirty floors and stained, frayed carpet on a hall and in dining areas, but the issues were not shown to have been followed up on. The HD said she had no documentation of follow-up, and surveyor observation found the dining room floor dirty with a sticky glaze and the carpet heavily stained and frayed; the HD also said the facility's brushing machine was broken and carpet shampooing had not been possible.
A resident with severe cognitive impairment and a history of wandering was not accurately assessed in the MDS, as the assessment failed to document wandering behaviors that were noted in progress notes and by staff. Despite the resident's documented exit-seeking and the use of a wander guard, the MDS did not reflect these behaviors, and staff interviews confirmed the inaccuracy.
A resident admitted with alcoholic cirrhosis did not receive ordered doses of gabapentin and sucralfate as scheduled because the medications were not available at the time of administration, and there was no documentation explaining the missed doses. Although the facility had an automated medication system with gabapentin, many agency nurses lacked access, and the medications were not delivered until the next day. The MAR indicated the missed doses, but no explanation was found in the progress notes.
Administrative staff did not conduct a comprehensive investigation after a resident with exit-seeking behaviors eloped from the facility. The assigned LPN did not follow the missing person protocol, and the Administrator was not promptly notified. The facility failed to inform the resident's responsible party, and the investigation included only a single staff statement, omitting interviews with other involved staff.
A resident with known exit-seeking behaviors eloped from the facility without staff knowledge, and the assigned LPN did not follow the missing person protocol. The Administrator was not promptly notified, and the resident's family learned of the incident directly from the resident. The facility's investigation was incomplete, and the event was not reviewed by the QAPI committee as required by policy.
A facility failed to protect resident dignity when an LPN entered a resident’s room without knocking or asking permission, a fingerstick blood sugar was done at a dining table in view of others, and a CNA stood over a resident while feeding. In addition, three residents seated together in the dining room did not receive their lunch trays at the same time, despite staff and DON expectations that residents should be served together and that feeding should be uninterrupted and seated.
Failure to Complete Required Quarterly Self-Administration Assessments: The facility did not complete required quarterly self-administration assessments for two residents who were keeping and using their own medications. One resident with intact cognition and diagnoses including HF, HTN, and DM had a self-administration screen from the prior year, but no evidence of the required ongoing quarterly review. Another resident with emphysema and chronic respiratory failure had an order for unsupervised inhaled medication, but the chart contained no self-administration safety screen assessment even though staff observed the resident carrying and using the inhaler independently. The DON and Administrator stated quarterly reassessment was expected.
A resident’s room was not free of pests, and the facility did not have documentation showing monthly pest control inspections as required by policy. Staff and the resident reported repeated stink bugs in the room, with surveyors observing dead and live bugs on the floor, curtains, ceiling, and window. The resident had intact cognition and diagnoses including stroke, HF, and HTN. The Maintenance Director later noted a gap around the door seal that allowed bugs to enter, while the DON and Administrator were unaware of the issue.
Facility staff did not follow abuse prevention policies for volunteer screening, as eight of nine volunteers lacked criminal background checks and seven did not complete required self-questionnaires. Volunteers, including church members and a former resident, participated in activities without proper pre-screening, contrary to facility policy.
Two residents were allowed to self-administer medications without a prior assessment or physician's order, as required by facility policy. An LPN left oral medications at the bedside for the residents to take unsupervised, and one resident was also found with an inhaler at the bedside without proper authorization. The DON and staff confirmed that no assessments or orders were in place, and the required procedures for self-administration were not followed.
An LPN prepared oral medications in advance and left them unattended and unsecured at the bedside for two cognitively intact residents, without observing one of them take the medications. Neither resident had been assessed or authorized for self-administration, and facility policy required medications to be administered at the time of preparation and under observation. The DON and staff development coordinator confirmed these actions did not meet professional standards.
A resident with multiple complex medical conditions did not receive a scheduled dose of IV Zosyn as ordered, with no documented reason or discontinuation order. Facility staff and administration could not explain the missed dose, and the responsible LPN was unavailable for clarification. Facility policy requires medications to be administered per prescriber orders, which was not followed in this case.
Staff failed to secure medications as required, with an inhaler left on a bedside table for a resident not authorized for self-administration, and oral medications prepared and left unattended in the rooms of two residents by an LPN. Facility policy requires medications to be locked and residents to be observed during administration, but these procedures were not followed.
A facility failed to include insulin administration in the baseline care plan for a resident admitted with an insulin pump. Despite the resident's ability to manage the pump independently, as confirmed by a nurse practitioner, the care plan lacked documentation of goals or interventions related to the insulin pump. This oversight was acknowledged by the regional nurse consultant, highlighting a deviation from the facility's care planning policy.
A resident's care plan was not updated to reflect their weight-bearing status, despite having physician's orders indicating changes. Interviews with staff revealed reliance on therapy evaluations and nursing reports for this information, but the care plan lacked the necessary updates. This deficiency was noted during a clinical record review and discussed with facility administration.
The facility experienced a deficiency in dietary staffing, resulting in delayed breakfast service. On a specific day, the scheduled cook and dietary aides were absent, leaving only the dietary manager to manage meal preparation. Consequently, a continental breakfast was served late, while lunch and dinner were on time. Communication issues between the new dietary manager and administrator contributed to the situation.
The facility failed to provide a timely breakfast service on four units due to the absence of kitchen staff. Scheduled breakfast times were not met, and residents received only cereal and milk around 10:30 a.m. The dietary manager, newly hired, decided to focus on lunch and dinner preparation. The administrator and DON were aware of the staffing issue but did not fully understand its impact on meal service. The facility's policy requires meals to be served at regular times, with no more than 14 hours between dinner and breakfast unless a substantial snack is provided.
The facility failed to provide therapeutic diets and serve meals accurately according to meal tickets for several residents. A resident with diabetes did not receive a diabetic diet, while another resident with congestive heart failure received meals not matching their dietary orders. The dietary manager acknowledged software issues causing meal ticket inaccuracies, but staff continued to serve incorrect meals. These issues were discussed with facility leadership without resolution before the survey ended.
The facility failed to maintain sanitary conditions in the main kitchen and two kitchenettes, with food stored beyond use-by dates, improper labeling, and unsealed items in the freezer. In the 200 and 300-unit kitchenettes, food was served below safe temperatures without reheating. The dietary manager acknowledged these issues, noting that policies for food safety and staff attire were not followed.
A resident with specific medical conditions did not receive the preferred number of showers twice weekly as requested, with records showing missed showers over several weeks. The responsible CNA was unavailable for comment, and the LPN confirmed the lack of documentation for any refusals. The DON, not present during the period in question, could not explain the deficiency.
A resident with multiple diagnoses did not have their treatments properly documented by nursing staff, despite physician orders and facility policy requiring immediate documentation. The Director of Nursing and an LPN confirmed the failure to document, although the treatments were reportedly completed.
A resident with multiple health conditions did not receive prescribed treatments, including topical powder, zinc cream, and leg wrap changes, as ordered by a physician. The treatment administration record was left blank, and no explanation was provided for the omission. The issue was confirmed by the LPN and DON, and the resident's care plan highlighted the risk of skin breakdown due to their condition.
The facility failed to serve food at an appetizing temperature on the 200-unit, with ongoing resident complaints about cold meals documented in council minutes. Observations revealed food items below the required temperature, and the dietary aide did not reheat them. Interviews with the RD and dietary manager showed a lack of awareness of the issue, despite frequent resident complaints.
A resident with specific dietary needs and preferences was not served meals according to their meal ticket, which included a heart-healthy, low-salt diet. The resident, who was cognitively intact and had conditions such as congestive heart failure, was served items not listed on the ticket and did not receive items that were listed. The dietary manager confirmed the discrepancy, and the issue was discussed with facility leadership.
Two residents with cognitive impairments and dysphagia did not receive necessary feeding assistance during meals. One resident was left with a meal unattended and without dentures, while another engaged in inappropriate eating behaviors without staff intervention, despite being identified as needing assistance. Facility guidelines for feeding assistance were not followed.
A resident who was always incontinent and required maximum assistance did not receive timely incontinence care, resulting in saturated clothing. The resident's daughter, who visits daily due to care concerns, reported that no staff provided care for several hours. The DON confirmed the lapse in care, acknowledging the standard of care was not met.
A resident admitted with traumatic brain injuries was enrolled in hospice care, but the facility failed to maintain a complete clinical record of hospice services, including documentation of care and involvement at the time of death. The DON confirmed the absence of hospice notes, which were later provided after the surveyor's review.
Failure to Prevent Elopement and Inadequate Supervision of Exit-Seeking Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions for residents identified as having exit-seeking behaviors, resulting in multiple deficiencies. One resident with a history of dementia, cognitive impairment, and exit-seeking behavior was admitted and initially assessed as low risk for elopement, despite documentation of wandering and a prior history of exit-seeking at the hospital. The resident was provided with a wander guard, but staff did not accurately update the elopement risk assessment when the resident continued to display exit-seeking behaviors. On the day of the incident, the resident expressed a desire to leave, was redirected multiple times, and ultimately eloped from the facility without staff knowledge. The facility failed to promptly and correctly implement its missing resident protocol (Code Orange), with staff not announcing the code as required, not stationing staff at all exits, and not completing required documentation. The resident was later found offsite by local authorities after a family member was contacted by the resident. Another resident with dementia and moderate cognitive impairment also exhibited exit-seeking behaviors, including multiple attempts to exit the facility and setting off alarms. Despite these behaviors, the facility did not complete updated elopement risk assessments as required by policy. The resident was ordered to have a wander guard, but there was an incident where the resident removed the device, and it was not immediately replaced by staff. The resident's information was also missing from the facility's elopement binder, which staff relied upon to identify residents at risk for elopement. Staff interviews revealed a lack of awareness regarding the need for reassessment and inconsistent monitoring of the wander guard's placement and function. Throughout these incidents, facility staff demonstrated a lack of adherence to established policies for elopement risk assessment, care planning, and emergency response. Staff failed to communicate effectively, did not follow the required steps for Code Orange activation, and did not ensure that all staff were aware of their roles during a missing resident event. Documentation was incomplete or missing, and not all staff involved were interviewed during the facility's internal investigation. These failures affected at least two residents and resulted in noncompliance with federal requirements for accident prevention and resident safety.
Removal Plan
- Resident was placed on 1:1 supervision to ensure safety and to not leave the building unattended once returned to the building.
- Resident was evaluated by nursing staff with no new impairments and seen by the nurse practitioner (NP).
- Resident remained on 1:1 supervision and discharged from the facility.
- Resident was placed on 1:1 supervision as a precaution.
- The wander guard was placed back on Resident and secured the same day it was observed to be off.
- Admission Record for Resident was placed in the elopement binder at the front desk; all other binders on the units were already updated.
- The facility licensed nursing staff will conduct new elopement assessments on all residents to determine elopement risk with follow-up based on findings.
- Any newly identified residents will be assessed for a wander guard by Director of Nursing, and it will be placed appropriately.
Failure to Resolve Resident Council Grievances
Penalty
Summary
The facility failed to ensure prompt resolution of grievances voiced by residents during Resident Council meetings. A facility policy titled Service Concerns/Grievances stated the Administrator was responsible for ensuring management staff were trained to resolve in-house patient/family concerns and grievances as promptly as possible, and that the Administrator served as the grievance official responsible for overseeing the grievance process and tracking concerns to conclusion. During the Resident Council meeting, Resident #72, Resident #96, and Resident #80 each voiced ongoing concerns about the condition of the 200 Hall, including sticky floors, dirty dining room floors, stained carpet, peeling carpet, and carpet that needed to be shampooed more often. The residents stated these concerns had been raised repeatedly and that staff had told them they would look into them, but the issues remained unresolved. Record review showed the three residents had intact cognition, with BIMS scores of 15 on quarterly MDS assessments. Resident Council minutes from 03/2025 through 08/2025 documented repeated complaints about carpets needing shampooing, dirty dining areas, sticky dining room floors, and carpet needing vacuuming and shampooing more often. The Housekeeping Director stated she did not have anything to show the concerns had been followed up on. During observation of the 200 Hall, the surveyor noted the dining room floor was dirty and had a sticky glaze, and the carpet was heavily stained and frayed and needed replacement. The Housekeeping Director stated the floor stayed that way and staff tried to mop it regularly, and she confirmed the facility's brushing machine had been broken and they had not been able to shampoo the carpet. The DON and Administrator stated grievances voiced during the Resident Council meeting should be addressed.
Inaccurate MDS Assessment for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one resident who was reviewed for accidents. The MDS, which is used to assess behavioral symptoms such as wandering, did not accurately reflect the resident's behaviors during the required 7-day look-back period. Specifically, the MDS indicated that the resident did not exhibit wandering behaviors, despite documentation and staff interviews confirming that the resident had a history of exit-seeking behavior, had wandered to other units, and required a wander guard for safety. The resident had severe cognitive impairment, dementia, and other medical conditions that placed them at risk for elopement, as noted in the care plan and progress notes. Staff interviews, including those with the LPN who documented the wandering and the MDS Coordinator, confirmed that the MDS assessment was not completed accurately and should have indicated the presence of wandering. The Staff Development Coordinator/Infection Preventionist, who was acting as the Director of Nursing, and the Administrator both acknowledged that the MDS was inaccurate and that staff were expected to follow the RAI manual. The deficiency was identified through interviews, record review, and document review, which demonstrated a failure to accurately assess and document the resident's wandering behavior as required.
Failure to Provide Timely Ordered Medications Due to Access and Delivery Issues
Penalty
Summary
The facility failed to ensure that ordered medications were available and administered as prescribed for a resident admitted with a diagnosis of alcoholic cirrhosis. Upon admission, the resident had physician orders for gabapentin and sucralfate to be administered at specific times, including a 9:00 PM dose on the day of admission. Review of the Medication Administration Record (MAR) showed that the 9:00 PM doses of both medications were not administered, and the MAR entry indicated 'Other / See Progress Notes,' but there was no documentation in the progress notes explaining the missed doses. Further investigation revealed that the medications were not delivered to the facility until the following morning, as confirmed by the pharmacy delivery manifest. Interviews with staff indicated that while the facility had an automated medication management system containing gabapentin, many agency nurses did not have access to it, and no medication was pulled from the system for this resident. The DON confirmed that most medications for the resident were not due until the next day, but the missed 9:00 PM dose was not addressed or documented appropriately.
Failure to Conduct Thorough Investigation After Resident Elopement
Penalty
Summary
The administrative staff failed to conduct a thorough investigation following the elopement of a resident identified as having exit-seeking behaviors. On the evening of the incident, the resident left the facility without staff knowledge, and the assigned LPN did not implement the facility's missing person protocol (Code Orange) as specified. The Administrator was not notified of the elopement until nearly two hours after the resident had left, and the resident's responsible party was not informed by the facility that the resident was missing. Instead, the resident contacted a family member directly, who then notified the facility of the resident's location. The resident was subsequently returned to the facility by local police and a staff member. The facility's investigation into the incident was incomplete, containing only a statement from the LPN involved and lacking interviews with other staff who were on duty or participated in the search for the resident. During interviews, the Administrator acknowledged that additional staff interviews should have been conducted and that a root cause analysis was necessary to determine where the process failed. The deficiency was identified through review of facility documents and staff interviews, which confirmed that the investigation did not meet the expected standards outlined in the job descriptions for the Administrator and Director of Nursing.
Failure to Review Resident Elopement in QAPI Committee
Penalty
Summary
The facility failed to ensure that a resident elopement incident was reviewed by the Quality Assurance and Performance Improvement (QAPI) committee, as required by facility policy. A resident identified as having exit-seeking behaviors eloped from the facility without staff knowledge. The assigned LPN did not implement the facility's missing person protocol (Code Orange) as specified. The Administrator was not notified of the elopement until nearly two hours after the resident left, and the resident's responsible party was not informed by staff that the resident was missing. Instead, the resident contacted their family directly, who then notified the facility of the resident's location. The resident was subsequently returned to the facility by local police and a staff member. The facility's investigation into the incident was incomplete, containing only a statement from the assigned LPN and lacking interviews with other staff on duty or those involved in the search. Despite facility policies and QAPI guidelines requiring the committee to review reportable incidents and undesirable outcomes, the elopement was not brought before the QAPI committee for review. Both the acting DON and the Administrator confirmed in interviews that the incident had not been reviewed by the QAPI committee, contrary to expectations and established procedures.
Failure to Protect Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to promote dignity for 6 of 27 sampled residents by not consistently protecting privacy, respecting personal space, and providing meals in a dignified manner. Facility policy stated residents had the right to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care for personal needs. The Director of Nursing and Administrator stated that medication-related procedures should not be done in open areas when privacy was needed, and that staff should sit with residents and provide uninterrupted meals. Resident #112, who was admitted with dementia and had a BIMS score of 6 indicating severe cognitive impairment, was observed when an LPN entered the room without knocking or asking permission. The LPN handed the resident medication and water and did not communicate with the resident until leaving the room. The resident stated staff never knocked before entering and said, “I wish they would knock.” The LPN later stated that knocking and announcing herself was the expected process and that she had rushed and failed to do so on that occasion. Resident #7, who had type 2 diabetes mellitus and a BIMS score of 3, was observed having a fingerstick blood sugar completed while seated at a dining table with other residents present. The same resident was later fed lunch while seated in the dining area, with the CNA standing over the resident and leaving and returning during the feeding. Residents #8, #47, and #97, all with severe cognitive impairment and varying levels of assistance needed for eating, were seated together in the dining room but did not receive their lunch trays at the same time; one resident received a tray first while the others waited, and the remaining trays were delivered several minutes later. Staff and leadership stated that residents seated together should be served at the same time and that staff should sit with residents during feeding.
Failure to Complete Required Quarterly Self-Administration Assessments
Penalty
Summary
The facility failed to conduct an ongoing quarterly assessment to determine whether residents could safely self-administer their medications as required by facility policy. The policy titled, Self-Administration of Medication at Bedside, effective 01/29/2024, stated a licensed nurse would assess the patient’s ability to self-administer medication, the interdisciplinary team would determine eligibility, and the Medication Self-Administration Safety Screen assessment would be reviewed quarterly. The report identified two residents reviewed for choices who were self-administering medications without the required quarterly reassessment being documented. Resident #72 had a quarterly MDS with an ARD of 09/04/2025 showing intact cognition with a BIMS score of 15 and diagnoses including heart failure, hypertension, and diabetes mellitus. The care plan stated the resident preferred to self-administer medications and included interventions for quarterly review of self-administration safety screens and reassessment by the interdisciplinary team. The resident’s Medication Self-Administration Safety Screen, dated 08/16/2024, stated ongoing assessment should occur at a minimum of quarterly, but the medical record contained no evidence that staff completed an ongoing assessment at least quarterly. During observation and interview, the resident stated they self-administered medications and kept them in a locked utility box in the room. The DON acknowledged that a quarterly assessment had not been completed since the 08/16/2024 assessment, and the Administrator stated she expected quarterly reassessment. Resident #87 was admitted with diagnoses including emphysema, chronic respiratory failure, and anxiety disorder, and a quarterly MDS with an ARD of 08/01/2025 showed a BIMS score of 14. The care plan indicated the resident preferred to self-administer inhaled medications, and the order summary included Atrovent HFA inhalation aerosol solution for unsupervised self-administration. However, the medical chart contained no evidence of a medication self-administration safety screen assessment. During observation and interview, the resident was seen with an inhaler in a shirt pocket and stated they kept it with them for emergencies and used it themselves. CNA #11 and RN #12 both stated the resident kept and administered the inhaler independently, and RN #12 stated the resident should have had an assessment but was not sure one had been completed. The DON and Administrator both stated that quarterly assessment was expected for residents self-administering medications.
Pest Control Program Not Maintained; Resident Room Had Stink Bugs
Penalty
Summary
The facility failed to ensure that one sampled resident’s room was free of pests and failed to follow its pest control policy requiring monthly inspection and treatment by a corporate-approved contractor. The facility provided a pest service receipt showing pest control maintenance was completed on 06/30/2025, but it was unable to provide documentation of any other monthly pest control inspections. The resident involved was admitted on 05/02/2017 and had a BIMS score of 13, indicating intact cognition, with active diagnoses including stroke, heart failure, and hypertension. During observations and interviews, the resident repeatedly reported and the surveyor observed stink bugs in the room. On 09/22/2025, the resident stated they always had to kill stink bugs in the room, and the surveyor observed 20 dead stink bugs on the floor leading to the outside area and two stink bugs crawling on the curtain and ceiling. On 09/23/2025, dead bugs were again observed on the floor, and later that day 18 dead stink bugs and four live stink bugs were observed on the window and curtains. The resident stated the bugs were the same ones from the prior day and that staff had been told, but nothing had been done. The Maintenance Director later stated there was a gap in the door around the seal to the wall that allowed bugs to enter the room, and the DON and Administrator stated they were not aware of the concern.
Failure to Screen Volunteers per Abuse Prevention Policy
Penalty
Summary
Facility staff failed to follow established abuse prevention policies regarding the screening of volunteers. Specifically, eight out of nine volunteer records reviewed showed that no criminal background check had been performed, and seven out of nine volunteers did not have a completed self-questionnaire about past or pending criminal charges. The activity director confirmed that volunteers, including a pastor, a former resident, and several church members, assisted with activities such as games and music. The activity director stated that all volunteers were supposed to complete an application and a self-questionnaire, which would then be reviewed by the administrator and human resources (HR) before a criminal background check was conducted. However, review of facility records and staff interviews revealed that these steps were not followed for most volunteers. The HR manager, who had been in her position since April 2025, reported that no new volunteer screenings had been requested or performed during her tenure, and a search of her portal confirmed that eight current volunteers had no criminal background check on file. The administrator acknowledged that background checks were required prior to volunteer service and that the activity director was responsible for obtaining the necessary documentation, while HR was responsible for conducting the background checks. The facility's abuse prevention policy clearly outlined these pre-screening requirements, but they were not adhered to for the majority of volunteers reviewed.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
Facility staff allowed two residents to self-administer medications without conducting a prior assessment or obtaining a physician's order, as required by facility policy. Both residents were assessed as cognitively intact and had multiple medical diagnoses, including diabetes, asthma, atrial fibrillation, spinal stenosis, and hypertension. On the evening in question, an LPN prepared and left oral medications at the bedside for these residents to take upon returning to their rooms, without witnessing the administration or ensuring the medications were secured. The LPN stated this was done to expedite the medication pass, and later confirmed that one resident self-administered the medication while the other was observed taking it after the LPN returned to the room. Clinical record review revealed that neither resident had a physician's order or an interdisciplinary assessment authorizing self-administration of medications. Interviews with the DON and staff development coordinator confirmed that the facility's policy requires both an assessment and a physician's order before residents are permitted to self-administer medications, and that medications should not be left unattended at the bedside. The DON also stated that residents approved for self-administration are provided with a lock box for medication storage, which was not the case for these residents. Additionally, one resident was found with a Trelegy Ellipta inhaler at the bedside, which had been used, without a physician's order or assessment for self-administration. The resident reported self-administering the inhaler daily, and staff were unaware that the device was in the room. Facility policy requires a licensed nurse to assess the resident's ability to self-administer, with interdisciplinary team review and documentation in the medical record, none of which was completed for this resident.
Medications Left Unattended and Unsecured at Bedside
Penalty
Summary
Facility staff failed to follow professional standards of quality during medication administration for two residents. On the evening in question, an LPN prepared oral medications ahead of the scheduled administration time and left them unattended and unsecured at the bedside for two cognitively intact residents. The LPN did not observe one of the residents taking the prepared medications, and only later confirmed with the resident that the medications had been taken. For the other resident, the LPN found the medications still at the bedside later in the evening and then observed the resident taking them. Both residents had complex medical histories, including conditions such as diabetes, atrial fibrillation, chronic kidney disease, spinal stenosis, and hypertension. Interviews with the LPN revealed that the medications were prepared and left at the bedside to expedite the medication pass, despite the LPN's awareness that this practice was not permitted. Neither resident had been assessed for self-administration of medications, nor was there a physician's order or interdisciplinary team assessment indicating they were safe to self-administer. Facility policy required that medications be administered at the time they are prepared, not left unattended, and that residents be observed to ensure the dose is ingested. The facility's DON and staff development coordinator confirmed that the observed practices did not align with facility policy or professional standards.
Missed Dose of IV Antibiotic Due to Failure to Follow Physician Order
Penalty
Summary
Facility staff failed to follow physician orders for medication administration for one resident. The resident, who was cognitively intact and had multiple diagnoses including osteomyelitis, MRSA, end stage renal disease, protein-calorie malnutrition, anemia, hypertension, and diabetes, had a physician's order for Zosyn (piperacillin-tazobactam) IV to be administered every 12 hours for treatment of acute osteomyelitis. The medication administration record showed that the scheduled 6:00 a.m. dose on 2/11/25 was not given, and there was no documented reason or physician order to discontinue or stop the medication at that time. A nursing note ambiguously stated "Informed IV completed," but this was not supported by any discontinuation order or further explanation in the clinical record. Interviews with the DON, RN infection preventionist, and regional nurse consultant confirmed that the Zosyn order was not discontinued or completed on the date in question, and they were unable to explain why the dose was missed. The nurse practitioner confirmed awareness of the missed dose and stated that the resident's labs and vital signs remained stable, with no indication to alter the antibiotic regimen. The LPN responsible for the missed dose was unavailable for interview. Facility policy requires medications to be administered according to prescriber orders, which was not followed in this instance.
Medications Left Unsecured and Unattended in Resident Rooms
Penalty
Summary
Facility staff failed to ensure that medications were securely stored and not left unattended, as required by professional standards and facility policy. In one instance, a Trelegy Ellipta inhaler prescribed for a resident with asthma, diabetes, and other chronic conditions was found unsecured on the resident's bedside table. The resident had not been assessed or authorized for self-administration of medications, and both the LPN and the DON confirmed that medications should not be left at the bedside unless the resident is assessed and has a physician's order for self-administration, with medications kept in a locked box. Additionally, on another occasion, an LPN prepared oral medications for two residents and left them on their bedside tables while the residents were in the dining room. The LPN admitted to leaving the medications unattended to expedite her medication pass, despite knowing this was against facility policy. One resident reported taking the medication upon returning to her room, while the other was later observed by the LPN taking the prepared medication. There was no documentation or assessment indicating that either resident was permitted to self-administer medications. Facility policy clearly states that medications must be administered within 60 minutes of the scheduled time, medication carts must be locked when not in use, and residents must be observed to ensure medication ingestion. The DON and staff development coordinator confirmed that these policies were not followed in the incidents described, and that medications should not be left unsecured or unattended in resident rooms.
Failure to Include Insulin Pump Management in Baseline Care Plan
Penalty
Summary
The facility staff failed to include insulin administration in the baseline care plan for a resident who was admitted with an insulin pump. The resident, who was cognitively intact and oriented, had a medical history that included diabetes, Parkinson's, and other conditions. Upon admission, the resident's baseline care plan did not document any goals or interventions related to the use of the insulin pump, despite the resident's demonstrated ability to manage the pump independently as noted in the hospital discharge summary. The nurse practitioner assessed the resident and confirmed the resident's capability to manage the insulin pump, indicating that the resident could continue using the pump in the facility as they did in the hospital. However, the baseline care plan still lacked documentation regarding the insulin pump, which was acknowledged by the regional nurse consultant during an interview. The facility's care planning policy requires the development and implementation of an individualized care plan to provide effective, person-centered care, which was not adhered to in this case.
Failure to Update Resident Care Plan with Weight-Bearing Status
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for one resident, identified as Resident #13, regarding their weight-bearing status. During interviews, the therapy manager confirmed that Resident #13 was non-weight bearing on the right leg, and this information was not updated in the resident's care plan. A certified nursing assistant (CNA) and a licensed practical nurse (LPN) both indicated that they rely on therapy evaluations and nursing reports to understand a resident's weight-bearing status. However, the interim director of nursing and the regional nurse consultant both expected this critical information to be included in the care plan, which was not the case. A clinical record review revealed that Resident #13 had a physician's order dated 8/6/24 indicating non-weight bearing status on the right lower extremity, which was later updated on 8/26/24 to allow weight application to the foot during transfers. Despite these orders, the care plan did not reflect the resident's current weight-bearing status, leading to a deficiency in the facility's care planning process. This oversight was discussed in an end-of-day meeting with the facility's administration and regional representatives, but no additional information was provided to address the deficiency at that time.
Insufficient Dietary Staffing Leads to Delayed Breakfast Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal delivery on four units, as observed on 6/9/24. On this date, the dietary department's as-worked schedule showed that no dietary employees, except the dietary manager, were present in the main kitchen. The scheduled cook and five dietary aides either called out, went home, or were no-shows. Consequently, the dietary manager, who was newly hired, decided to serve a continental breakfast of cereal and milk around 10:30 a.m. to focus on preparing lunch and dinner. The dietary manager stated that she typically required one cook and at least four dietary aides for timely meal service. Interviews with the dietary manager, a dietary aide, the administrator, and the DON revealed communication issues and a lack of awareness about the staffing shortage. The administrator, also new to the facility, was informed of the call-outs but did not grasp the significance of the missing staff. The dietary manager did not fully communicate the situation, leading to the decision to serve a modified breakfast without the administrator's input. Despite the staffing challenges, lunch and dinner were served on time, and there were no reported issues experienced by residents due to the modified breakfast.
Failure to Provide Timely Breakfast Service Due to Staff Absence
Penalty
Summary
The facility staff failed to provide a timely breakfast service on four units due to a lack of kitchen staff on the morning of 6/9/24. The scheduled breakfast times were 8:00 a.m. for the 200 and 300 units and 8:30 a.m. for the 100 and 400 units. However, no cooked breakfast was served, and residents only received cereal and milk around 10:30 a.m. The dietary department's as-worked schedule revealed that no dietary employees worked in the main kitchen that morning, as the cook and five dietary aides either called out, went home, or were no-shows. The newly hired dietary manager, who started on 6/4/24, decided to provide a continental breakfast to focus on preparing lunch and dinner on time. The dietary manager stated that conflicts with the cook contributed to the absence of kitchen staff. The administrator and DON were informed of the staffing issue but did not fully comprehend the impact on meal service. The administrator acknowledged poor communication and stated that if she had been fully informed, she would have arranged for facility staff to assist. The facility's policy requires meals to be served at regular times, with no more than 14 hours between dinner and breakfast unless a substantial snack is provided. The failure to provide a timely breakfast service was reviewed with the administrator, DON, and regional director of clinical services, with no further information presented before the end of the survey.
Failure to Provide Therapeutic Diets and Accurate Meal Service
Penalty
Summary
The facility staff failed to provide a therapeutic diet and serve foods correctly per meal ticket for four out of five residents in the survey sample. Resident #2, who had diagnoses including diabetes, anemia, and anorexia, was not provided a diabetic diet for lunch and was missing items for breakfast. Similarly, Resident #3, with diabetes, gout, and obesity, was not served a diabetic diet for lunch. Resident #4, diagnosed with neuropathy and dysphasia, did not receive the correct breakfast items as per the meal ticket. Observations revealed that the serving line did not have pre-cut cupcakes for diabetic diets, and staff were unaware of missing items until prompted. Resident #1, who was cognitively intact and had diagnoses including congestive heart failure and hypertension, was not served foods according to the meal ticket. The meal ticket inaccurately documented a 1500 ml per day fluid restriction, which was not a current order. The resident frequently received meals that did not match the ticket, including items not wanted or supposed to be consumed. The dietary manager acknowledged the inaccuracies in the meal ticket system but was unsure how to correct them, leading to discrepancies in meal service. The dietary manager admitted to being aware of the software issues causing inaccuracies in meal tickets but did not know how to resolve them. The kitchen staff were expected to serve meals according to the tickets, which included resident preferences and therapeutic foods, but this was not consistently done. The findings were discussed with the administrator, director of nursing, and regional director of clinical services, but no further information was provided before the survey concluded.
Sanitation and Food Safety Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The facility staff failed to maintain sanitary conditions in the main kitchen and two kitchenettes, leading to multiple deficiencies. In the main kitchen, food items were stored beyond their use-by dates, lacked proper labeling, and were unsealed in the freezer, exposing them to air. The bulk condiment storage containers, flour and sugar bins, and the manual can opener were found dirty. An employee was observed in the kitchen without a hair restraint during meal preparation, and personal food items were improperly stored in the walk-in refrigerator. In the 200 and 300-unit kitchenettes, food was held on steam tables below the recommended safe temperatures and served to residents without reheating. The dietary aides on both units failed to check food temperatures before serving, and when temperatures were checked, multiple food items were found below the required 135 degrees Fahrenheit. Despite this, the aides continued to serve the food without reheating it to the proper temperature. The dietary manager acknowledged the issues, stating that employee food should not be stored in the kitchen refrigerator and that scoops should not be stored in the flour and sugar bins. The manager also admitted that servers were supposed to check food temperatures at the steam tables and reheat any food below 135 degrees Fahrenheit before serving. The facility's policies and procedures, including those for food safety, staff attire, and cleaning schedules, were not adhered to, contributing to the deficiencies observed.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility staff failed to accommodate the bathing preferences of a resident, identified as Resident #1, who was admitted with diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema. The resident was assessed as cognitively intact and required supervision or touch assistance with bathing. During an interview, the resident expressed a preference for receiving two showers per week, which was not consistently met. The clinical records indicated that the resident did not receive the preferred number of showers during February and March 2024, with several weeks showing no showers or only one shower provided. The certified nurse's aide responsible for the resident's showers during the specified period was unavailable for interview, as she no longer worked at the facility. The LPN unit manager confirmed that residents requesting showers were scheduled for two per week and that any refusals should be documented, but found no such documentation in the resident's records. The DON, who was not employed at the facility during the time of the missed showers, could not provide an explanation for the oversight. The issue was discussed with the facility's administration, but no additional information was provided before the survey concluded.
Failure to Document Resident Care
Penalty
Summary
The facility staff failed to adhere to professional standards of care by not documenting treatments provided to Resident #1 at the time the care was administered. Resident #1, who was admitted with diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema, had physician orders for specific treatments such as Zeasorb-AF external powder, zinc barrier cream, and Circaid wraps. However, the treatment administration records (TARs) from September 1, 2024, through November 13, 2024, showed incomplete documentation for these treatments on multiple occasions. There were no notes indicating that the treatments were not performed or that the resident refused them. Upon review, the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the nurses failed to document the care provided, despite statements from the nurses indicating that the treatments were completed as ordered. The facility's policy requires documentation of medication administration immediately after care is provided, which was not followed in this case. The Lippincott Manual of Nursing Practice highlights the importance of prompt and accurate documentation, which was not adhered to, leading to this deficiency.
Failure to Administer Prescribed Treatments
Penalty
Summary
The facility staff failed to follow physician orders for a resident, identified as Resident #1, who was admitted with diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema. The resident was assessed as cognitively intact. The clinical record documented specific orders for the application of Zeasorb-AF external powder, zinc barrier cream, and the changing of Circaid leg wraps. However, on a specific date, these treatments were not administered as ordered, and the treatment administration record was left blank with no documentation of resident refusal or explanation for the omission. The issue was reviewed with the licensed practical nurse unit manager and the director of nursing, who confirmed that the treatments were not completed and that there was no explanation provided by the nurse responsible for the care on that day. The resident's plan of care, which was revised shortly after the incident, highlighted the risk of skin breakdown due to the resident's fragile skin and chronic health conditions, emphasizing the importance of the prescribed treatments. The deficiency was discussed with the facility's administration and clinical services team, but no further information was provided before the survey concluded.
Failure to Serve Food at Safe and Appetizing Temperature
Penalty
Summary
The facility staff failed to provide food at an appetizing temperature on the 200-unit, as evidenced by ongoing complaints from residents and observations made during the survey. Monthly resident council minutes from May 2024 through October 2024 documented repeated complaints about meals being served cold, with no documented follow-up or interventions noted. During an interview, the resident council president confirmed that residents frequently reported cold food, which had been a recurring topic in council meetings. On November 12, 2024, an observation of the meal service from the 200-unit kitchenette revealed that multiple food items were served below the required 135 degrees Fahrenheit. Despite this, the dietary aide did not reheat the foods, and service continued. Interviews with the registered dietitian and dietary manager indicated a lack of awareness and understanding of the source of the cold food complaints, with the dietary manager unaware of ongoing resident concerns and the specific issue of foods being served below the minimum temperature. These findings were discussed with the facility's administration, but no additional information was provided before the survey concluded.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility staff failed to provide food that accommodated the preferences of a resident, identified as Resident #1, who was part of the survey sample. Resident #1, who was cognitively intact and had diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema, was observed during a meal service where the food served did not match the meal ticket. The meal ticket specified a heart-healthy, low-salt diet with no pork, fried, or breaded foods, and recommended baked chicken, fresh vegetables, fruit, and yogurt. However, Resident #1 was served items not listed on the ticket, such as mashed potatoes, a roll, and a chocolate cupcake, and did not receive a tossed salad that was listed. The resident expressed that meals rarely matched his preferences and often included items he did not want or was not supposed to have. The dietary manager confirmed that the meal tickets, which included resident preferences and therapeutic foods, were not followed for Resident #1. The manager was unable to explain why the resident was not served the salad as listed. The resident's care plan, revised shortly before the survey, documented the risk of complications related to obesity, heart failure, and diet non-compliance, with interventions including a therapeutic diet and honoring food preferences. This deficiency was discussed with the facility's administrator, director of nursing, and regional director of clinical services, but no further information was provided before the survey concluded.
Failure to Provide Adequate Feeding Assistance to Residents
Penalty
Summary
The facility staff failed to provide adequate feeding assistance to two residents, resulting in deficiencies in care. Resident #4, who was diagnosed with dysphagia and moderate cognitive impairment, required extensive feeding assistance. However, during a breakfast observation, the staff left the meal within the resident's reach without remaining in the room to assist. Additionally, the resident's dentures were not placed in her mouth before eating, which was acknowledged by the LPN who assisted her. Interviews with CNAs revealed that meals should not be left unattended for residents needing assistance, and dentures should be placed before feeding. Resident #5, diagnosed with dysphagia, oropharyngeal phase, and severe cognitive impairment, also required extensive feeding assistance. During breakfast, the resident was observed engaging in inappropriate eating behaviors, such as drinking syrup and mixing oatmeal with coffee, without any intervention from the CNAs present in the dining room. Despite other residents alerting staff to the need for assistance, no help was provided. Interviews confirmed that the staff was aware of the resident's need for assistance, yet failed to act accordingly. The facility's documentation, based on Mosby's Textbook for Long-Term Care Nursing Assistants, outlines proper feeding assistance procedures, which were not followed in these instances.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility staff failed to provide timely incontinence care to a resident, identified as R2, who was always incontinent of bowel and bladder and required maximum assistance with all activities of daily living. On the day of the survey, the resident's daughter, who visits daily due to concerns about the care provided, reported that no staff had entered her mother's room to provide care from shortly after noon until 3 p.m. When the daughter sought assistance, it was discovered that R2's incontinence brief and pants were saturated with urine, indicating a lack of care over an extended period. The director of nursing (DON) confirmed that the standard of care for incontinence is every two hours, or more frequently if needed, and acknowledged the failure to provide care in this instance. The resident's care plan highlighted the risk of pressure ulcers due to immobility and incontinence, with interventions to keep the skin clean and dry. However, the facility lacked a specific policy on incontinence care, relying instead on general standards of practice. The incident was brought to the attention of the facility administration, but no further information was provided regarding corrective actions.
Incomplete Clinical Record for Hospice Resident
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident who was receiving hospice services. The resident was admitted to the facility with diagnoses including traumatic subdural hemorrhage and subarachnoid hemorrhage. A hospice consult was ordered, and the resident was enrolled in hospice services. However, the clinical record lacked documentation regarding hospice care, treatment, or involvement at the time of the resident's death, except for a hospice contract and a Record of Death document indicating that a hospice nurse pronounced the death. During an interview, the Director of Nursing (DON) acknowledged that hospice records should have been part of the resident's clinical record and confirmed that the hospice notes were not available when the surveyor accessed the closed record. The DON later provided documentation from hospice, which included notes of hospice nurse visits and details about the medical examiner's involvement. The facility administrator was informed of these findings during an end-of-day meeting.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 65 citations issued within 25 miles in the last 12 months — 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.
Illustrative
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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charlottesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Canterbury Blue Ri | 2.4 mi | ★★★★★ | 13 | 0 |
| Colonnades Health Care Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 4.4 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Charlottesville | 4.9 mi | ★★★★★ | 0 | 0 |
| Monroe Health & Rehab Center | 5.1 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Albemarle Health & Rehabilitation Center.
100% money-back within 48 hours.
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.