Albany Health Care & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Albany Health Care & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 9, 2021

  Based on observation, interview and record review, the facility failed to ensure a severely cognitively impaired resident, who was at risk for elopement, remained in the locked dementia unit for 1 of 3 residents reviewed for elopement (Resident B). The immediate jeopardy began on 8/22/21 when the severely cognitively impaired resident eloped from the facility's locked dementia unit and walked through the facility's fenced in area, through an unlocked gate and followed the fence line behind the facility and circled around to the front of the facility. The Administrator, DON, Nurse Consultant and ADON were notified of the immediate jeopardy at 4:10 p.m. on 9/8/21. […]

• Actual harm, isolatedF760Aug 16, 2023

  Based on interview and record review, the facility failed to prevent a significant medication error when QMA1 administered the wrong medications to Resident B and Resident C. This deficient practice resulted in Resident B being sent to the hospital where she was diagnosed with accidental drug ingestion and received treatment for lack of adequate oxygen to the body tissues (acute hypoxia), low blood pressure (hypotension), and slow heart rate (bradycardia). Findings include: Review of a 8/14/23 facility-reported incident to the Indiana Department of Health indicated Residents B and C had been administered each other's medications on 8/12/23. Resident B required transfer to the hospital for treatment. The clinical record for Resident B was reviewed on 8/16/2023 at 10:00 a.m. […]

• Actual harm, isolatedF689Aug 25, 2022

  Based on observation, interview and record review, the facility failed to ensure a resident's seatbelt was disconnected while in her motorized wheelchair and prior to being transferred with a mechanical lift for 1 of 3 residents reviewed for accidents (Resident B). This deficient practice resulted in the resident being lifted with a mechanical lift while secured to the wheel chair, which resulted in a [CONDITION(S)]. Findings include: During an interview with, CNA 21, on 8/24/22 at 2:03 p.m., she indicated she was not working on Resident B's hall that day and she was just assisting Agency CNA 6 with transferring Resident B from her powerchair to her bed. Before they hooked Resident B up to the Hoyer (mechanical lift), CNA 21 stepped out of the room to answer a call light. […]

• Actual harm, isolatedF600Jun 17, 2021

  Based on, interview and record review, the facility failed to prevent staff to resident abuse for 1 of 3 residents reviewed for abuse (Resident B). The facility also failed to protect a resident from abuse by a visitor for 1 of 3 residents reviewed for abuse (Resident C). This deficient practice resulted in Resident B being slapped and pinched by CNA 1 during care and Resident C receiving a black eye after an argument with a visitor. Findings include: 1. The clinical record for Resident B was reviewed on 6/17/21 at 8:41 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/18/21, indicated the resident was severely cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF576Jan 14, 2025

  Based on interview and record review, the facility failed to ensure mail was distributed to residents on Saturdays. This deficiency had the potential to affect 79 of 79 residents who resided in the facility. Finding includes: During a Resident Council group interview, on 1/10/25 beginning at 1:38 p.m., Resident 3 indicated the facility did not deliver mail to the residents on Saturdays. There was no one at the facility to deliver mail because the administrative offices were closed on the weekends. […]