Albemarle Health & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 25, 2025

  Based on observation, interview, record review, document review, and facility policy review, the facility failed to: provide supervision for a resident identified as having exit-seeking behaviors; develop and implement interventions to prevent a resident elopement; ensure the accuracy of elopement risk assessments and timeliness of reassessment upon the identification of exit-seeking behaviors; ensure the facility's protocol for a missing resident (Code Orange) was promptly and correctly implemented when Resident #127 eloped from the facility on 05/11/2025 without staff knowledge; ensure Resident #133, identified by the facility as being at risk for elopement had their admission Record included in the facility's elopement binder; and ensure Resident #133's wander guard was securely… […]

• Actual harm, isolatedF686Mar 6, 2024

  Based on observation, interviews, clinical record, and facility documentation, the facility staff failed to provide treatment and services to prevent a worsening stage three pressure ulcer for one of 12 residents, resulting in harm for Resident #8 (R8), and failed to assess and implement treatment timely for a stage three pressure ulcer for one of 12 residents in the survey sample, Resident #5 (R5). 1. R8 did not have an accurate skin assessment, resulting in a delay in treatment of a worsening stage three pressure ulcer/wound. 2. […]

• Actual harm, isolatedF689Sep 8, 2022

  Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation, the facility staff failed to ensure adequate supervision and/or interventions for the prevention of falls for one of 25 residents (Resident #111), which resulted in actual harm and failed to ensure one of 25 residents (Resident #7) was safe when consuming hot liquids. Findings include: 1.) Resident #111's diagnoses included, but were not limited to: ataxia [impaired coordination] following a non-traumatic intracerebral hemorrhage, [CONDITION(S)] syndrome, pancytopenia, headache, [CONDITION(S)], cognitive communication deficit, abnormalities of gait and mobility, lack of coordination, dysphagia, mild protein calorie malnutrition, high blood pressure, [CONDITION(S)],… […]

• No harm, potential for more than minimal, widespreadF802Nov 14, 2024

  Based on staff interview and facility document review, the facility staff failed to provide sufficient dietary staff to provide timely meal delivery on four of four units. The findings include: There was an insufficient number of dietary staff working on 6/9/24 to provide preparation and service of breakfast for residents within the facility. Review of the dietary department as-worked schedule for 6/9/24 revealed that no dietary employees worked in the main kitchen, other than the dietary manager. A hand-written employee schedule documented one cook, and five dietary aides were scheduled to work on 6/9/24 from 6:00 a.m. until 2:00 p.m. […]

• No harm, potential for more than minimal, widespreadF809Nov 14, 2024

  Based on staff interview and facility document review, the facility staff failed to provide timely breakfast service on four of four units. The findings include: There was no cooked breakfast provided to residents in the facility on the morning of 6/9/24. Posted breakfast times were 8:00 a.m. on the 200 and 300 units and at 8:30 a.m. on the 100 and 400 units. Posted mealtimes documented dinner was served daily at 5:00 p.m. (200, 300 units) and 5:30 p.m. (100, 400 units). Review of the dietary department as-worked schedule for 6/9/24 revealed no dietary employees worked in the main kitchen. A hand-written employee schedule documented one cook and five dietary aides were scheduled to work on 6/9/24, from 6:00 a.m. until 2:00 p.m. […]