Inspection Reports for
Albany Health Care & Rehabilitation Center

The complaint investigation found that the facility did not implement required fall prevention interventions for Resident C, who had multiple falls. The resident's care plan was not updated after moving to a secured unit where fall mats were not permitted. The deficiency was substantiated with observations and staff interviews.

The facility failed to ensure that fall prevention interventions, such as placing the bed against the wall, using non-slip mats in the wheelchair and recliner, and fall mats, were consistently implemented for Resident C. Observations and interviews confirmed that these interventions were not in place despite being in the care plan, contributing to multiple falls.

The complaint involved sexual abuse of Resident C by Resident B. The abuse was substantiated with multiple observations and statements. The facility delayed reporting the incident to the Administrator and other responsible parties, violating policy requirements.

The facility failed to protect a resident from sexual abuse by another resident and failed to immediately report the abuse allegation to the Administrator. The investigation found multiple incidents of sexually inappropriate behavior by Resident B towards Resident C and staff, with inadequate supervision and delayed reporting.

Complaint IN00462025 involved allegations of staff-to-resident abuse of Resident B. The complaint was substantiated with federal deficiencies cited at F600 and F609. The investigation confirmed bruising consistent with abuse and failure to timely report the incident.

The facility failed to ensure a cognitively impaired resident (Resident B) was free from staff-to-resident abuse, specifically physical retaliation by a staff member. The resident had bruising on bilateral wrists and left hand attributed to a staff member holding her arms. The staff member was terminated. The facility also failed to immediately report the alleged abuse to the administrator as required. The facility conducted a thorough investigation, provided staff education on abuse prevention and reporting, and implemented systemic corrective actions.

The complaint involved allegations that a CNA physically abused Resident B by holding and restraining her arms causing bruising. The abuse was substantiated. The facility failed to immediately report the abuse to the administrator. The staff member was terminated, and Adult Protective Services and local law enforcement were notified. The resident did not want to file charges.

The facility failed to ensure Resident B was free from staff-to-resident abuse when a CNA physically restrained the resident resulting in bruising. The facility also failed to immediately report the alleged abuse to the administrator. The investigation confirmed the abuse and the responsible staff member was terminated. The facility implemented corrective actions including staff re-education and monitoring.

The facility was found not in compliance with Life Safety Code requirements, including issues with locked exit discharge gates, missing exit signage, improper placement of cooking appliances under kitchen hood extinguishing systems, use of extension cords in place of fixed wiring, and lack of required maintenance and documentation for Patient Care Related Electrical Equipment (PCREE).

The facility was found deficient in multiple areas including mail distribution on Saturdays, availability of survey results, PASRR submission for a resident with new mental health diagnoses, comprehensive care planning, restorative care services, fall prevention supervision, and physician notification of significant weight loss.

The facility was cited for multiple deficiencies including failure to distribute mail on Saturdays, failure to maintain up-to-date survey reports, failure to submit PASRR for a resident with new mental health diagnoses, failure to develop and implement comprehensive care plans, failure to invite resident representatives to care planning, failure to provide restorative care, failure to provide adequate supervision to prevent falls, and failure to notify the physician of significant weight loss.

The facility was found not in compliance with emergency preparedness requirements due to failure to document 36-month emergency generator testing. Life Safety Code deficiencies included missing fire department connection signage, lack of GFCI protection on an electrical outlet near a sink, improperly grounded electrical receptacles in resident rooms, overdue annual testing of non-hospital grade receptacles, improper storage and segregation of oxygen cylinders, and failure to secure one oxygen cylinder.

The complaint investigation substantiated failures in ombudsman notification for hospital transfers, fall prevention care plan implementation, CNA certification compliance, and controlled medication record accuracy.

The facility failed to notify the Long-Term Care Ombudsman of hospital transfers for 2 of 3 residents reviewed. The facility also failed to implement care plan interventions to prevent falls for 1 of 5 residents reviewed. Additionally, the facility allowed CNA students to work beyond the allowed 120 days without certification. The facility failed to maintain accurate controlled medication records for 6 of 14 residents reviewed.

Complaint IN00424167 and Complaint IN00425811 were investigated with no deficiencies related to the allegations cited.

No deficiencies were cited related to the complaints investigated. Deficiencies were cited related to failure to notify the Long-Term Care Ombudsman of resident transfers, failure to implement fall prevention care plan interventions, use of uncertified CNA students beyond allowed time, and inaccurate controlled substance medication records.

Complaint IN00415086 was substantiated with a federal/state deficiency cited at F0760 related to the medication error incident.

The facility failed to prevent a significant medication error when QMA1 administered the wrong medications to Resident B and Resident C, resulting in Resident B being hospitalized for accidental drug ingestion and related complications. The facility implemented corrective actions including staff education, competency checks, and changes to resident identifiers.

This Federal tag relates to complaint IN00415086. The medication error was substantiated and resulted in actual harm to Resident B.

The facility failed to prevent a significant medication error when a qualified medication aide administered the wrong medications to two residents, resulting in one resident being hospitalized due to adverse effects including acute hypoxia, hypotension, and bradycardia. The error was discovered when a family member identified the residents correctly after medication administration, prompting immediate corrective actions.

This Federal tag relates to complaint IN00403125.

The facility failed to notify the physician and responsible party when a severely cognitively impaired resident verbalized intent for self-harm. The facility also failed to ensure timely reporting of abuse allegations to the Administrator and failed to develop and implement a behavioral care plan for the resident with self-harm verbalizations.

Complaint IN00403125 involved allegations related to failure to notify physician and family of self-harm statements by Resident B, failure to report abuse allegations regarding Resident C, and failure to develop a behavioral care plan for Resident B. The complaint was substantiated with deficiencies cited.

The facility failed to notify the physician and responsible party when a severely cognitively impaired resident verbalized intent for self-harm, failed to ensure staff reported allegations of abuse in a timely manner, and failed to develop and implement a behavioral care plan for the resident with self-harm verbalizations. Corrective actions and staff re-education were implemented.

The complaint investigation found that the resident was given Haldol for increased agitation without adequate indications and without prior use of non-pharmacological interventions. The Dementia Care Director and LPN interviews confirmed the resident's agitation and medication administration. The complaint was substantiated with findings.

The facility failed to ensure that a resident was not administered a PRN antipsychotic medication without proper indication or prior use of non-pharmacological interventions. The resident exhibited increased agitation and behavioral symptoms, and the facility administered Haldol without adequate indications.

Complaint IN00396346 was substantiated, but no deficiencies related to the allegations were cited.

The facility was substantiated for Complaint IN00396346 with no deficiencies related to the allegations cited. However, the facility failed to ensure a resident was not administered a PRN antipsychotic medication without indication for use or non-pharmacological interventions for 1 of 5 residents reviewed for unnecessary medications.

Complaint IN00388151 was substantiated. The complaint involved a resident being lifted with a mechanical lift while secured to a wheelchair seatbelt, resulting in a fractured hip.

The facility failed to ensure a resident's seatbelt was disconnected prior to transfer with a mechanical lift, resulting in the resident being lifted while secured to the wheelchair and sustaining a fractured hip. The investigation included interviews, record reviews, and observations confirming the incident and related deficiencies.