Albemarle Health & Rehab: MDS Documentation Failure - VA
The resident, identified in inspection records only as Resident 127, wanders and has been fitted with a wander guard, a device designed to prevent unsupervised exits. That detail matters because nursing homes use a standardized assessment tool, the Minimum Data Set, to track exactly these kinds of safety risks. The MDS shapes care planning, staffing decisions, and the level of supervision a resident receives. When it's wrong, the care built on top of it can be wrong too.
The assessment in question covered a window ending April 28, 2025. It did not indicate that Resident 127 had wandered in the past one to three days. According to the MDS Coordinator, interviewed by inspectors on October 21, it should have.
"The MDS was not completed accurately and should have indicated the presence of wandering," the MDS Coordinator told inspectors.
The finding was rated at the lower end of the harm scale, meaning inspectors determined the error caused minimal harm or the potential for actual harm rather than a documented injury. But the gap between what the record said and what was actually true about this resident's behavior and safety needs was not disputed by anyone at the facility.
The Staff Development Coordinator, who had taken over as acting Director of Nursing just nine days before inspectors arrived, was interviewed on October 23. She acknowledged the assessment was wrong. She said she expected MDS records to be accurate and for staff to follow the RAI manual, the federal guide that governs how these assessments are supposed to be completed. The administrator, interviewed the same morning, said the same thing.
Both statements were essentially agreements that the error happened and shouldn't have. Neither offered an explanation for why the wandering behavior was missing from the record in the first place.
The inspection was a complaint survey, meaning someone had raised a concern that prompted the visit. The deficiency was documented under F0641, which covers the accuracy of resident assessments. Inspectors completed their review on October 25, 2025.
What the record does not show is how long Resident 127's care plan reflected an assessment that undercounted their risk. The MDS with the April reference date was filed months before inspectors arrived. Whether any care decisions made during that interval were shaped by the incomplete picture of this resident's behavior is not addressed in the inspection findings.
The facility's acting Director of Nursing had been in that role for less than two weeks when inspectors came through. The circumstances that led to the leadership change are not described in the report.
Resident 127 was still there, still wearing a wander guard, still at risk of the kind of unsupervised movement that the guard was meant to prevent. The assessment that was supposed to document that risk had not captured it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Albemarle Health & Rehabilitation Center from 2025-10-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
ALBEMARLE HEALTH & REHABILITATION CENTER in CHARLOTTESVILLE, VA was cited for violations during a health inspection on October 25, 2025.
That detail matters because nursing homes use a standardized assessment tool, the Minimum Data Set, to track exactly these kinds of safety risks.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.