Albany Health Care & Rehabilitation Center

F-F688.

3.1-35 (a)

3.1-35(b)(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 45122

Residents Affected - Few Based on interview and record review, the facility failed to ensure the resident's representative was invited to participate in the ongoing care planning process for 1 of 1 residents reviewed for care planning. (Resident 34)

Findings include:

During an interview, on 1/8/25 at 11:19 a.m., Resident 34's representative indicated she had been invited one time to a care plan meeting. She had not been invited since that first meeting. She did not know when

the meetings were held.

Resident 34's clinical record was reviewed on 1/9/25 at 11:54 a.m. Diagnoses included anxiety disorder, delusional disorder, Alzheimer's disease, and unspecified dementia, moderate, with agitation.

An annual Minimum Data Set (MDS) assessment, dated 10/29/24, indicated the resident was severely cognitively impaired. An interview about preferences with the resident indicated having her family or a close friend involved in discussions about her care was very important to her.

A current care plan indicated Resident 34 did not plan to return to the community and wished to be asked about returning to the community on comprehensive assessments only (initiated 2/11/22 and revised 9/20/23). Interventions included the following: Encourage the resident's family to be involved in the resident's plan of care (initiated 2/11/22).

A progress note, dated 4/26/23 at 2:00 p.m., indicated a phone call was placed to the resident's representative to set up a care plan conference. The resident's representative was not reached, and a message could not be left as the voice mail had not been set up.

The clinical record lacked more recent documentation of attempts to invite the resident's representative to participate in the resident's care plan conferences.

During an interview, on 1/10/25 at 3:32 p.m., the Social Services Designee (SSD) indicated she invited the short term stay residents' representatives by phone. She invited the long-term stay residents' representatives by mail.

During an interview, on 1/14/25 at 10:51 a.m., the SSD indicated if the invitation to the care plan conference was not in the progress notes, then she did not have documentation that the resident's representative had been invited. The resident's representative visited the resident two to three times a week, and the resident's care was often discussed. She had invited the resident representative verbally to care plan conferences, but

she did not have documentation of those discussions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 A facility policy, revised 2/2019, titled Care Plan Meeting and Invitations, provided by the DON on 1/14/25 at 3:29 p.m., indicated the following: .SSD/Designee will send a standard letter to the Resident Representative Level of Harm - Minimal harm or or place a call to schedule the care plan meeting .The SSD/Designee will document that the letter was sent potential for actual harm or the phone call was made and the response received from the resident or the resident representative

Residents Affected - Few 3.1-35(d)(2)(B)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42685

Residents Affected - Few Based on interview and record review, the facility failed to provide appropriate restorative care services as recommended by therapy for a resident with limited range of motion for 1 of 1 resident reviewed for restorative care. (Resident 73)

Finding includes:

During an interview on 1/7/25 at 12:10 p.m., Resident 73 was laying in bed. He indicated he was paralyzed from his chest down. He had received therapy when he admitted a few months ago, but therapy ended. He was waiting for insurance to get more therapy. He had not received any restorative care or passive range of motion on his lower extremities to ensure he did not have a decline while he waited on insurance. He had spoken to two different therapy staff members quite some time ago and requested restorative care, but had not received any. He was concerned about losing the progress he had made in therapy.

The resident's clinical record was reviewed on 1/9/25 at 5:08 p.m. The resident admitted to the facility on [DATE REDACTED]. Diagnoses included, paralytic syndrome, constipation, complete paraplegia, other reduced mobility, generalized muscle weakness, and need for assistance with personal care.

A physician's medication order, dated 9/26/24, included baclofen 10 mg tablet- give 20 mg by mouth three times a day for muscle spasms, and was discontinued on 10/21/24.

Current physician's medication orders included the following: gabapentin (neuropathy pain reliever) 600 milligrams (mg) oral capsule by mouth three times a day for ascending paralysis, dated 9/13/24; baclofen (muscle relaxer) 20 mg tablet by mouth every six hours for spasms, dated 10/21/24; Senna-Plus (stool softener) 8.6-50 mg oral tablet by mouth twice daily for constipation, dated 9/13/24; Dulcolax (laxative) rectal suppository 10 mg rectally at bedtime every three days for constipation, dated 10/7/24

Review of the Medication Administration Record from October 2024 through January 2025 indicated the resident's baclofen was increased to four times daily after therapy ended due to increased spasms. An additional medication was added to treat constipation.

A current order, dated 9/12/24, indicated the resident's rehabilitation potential was fair.

The clinical record lacked current orders for speech therapy, occupational therapy, physical therapy, or restorative care services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 A quarterly Minimum Data Set (MDS) assessment, dated 12/21/24, indicated Resident 73 was cognitively intact. Rejection of care behaviors were not exhibited during the assessment period. The resident had a Level of Harm - Minimal harm or functional limitation in range of motion in the lower extremities with impairment on both sides. He was potential for actual harm dependent on staff for assistance with toileting, bathing, lower body dressing, footwear, rolling left and right, and transfers. He required substantial staff assistance for personal hygiene. Walking was not attempted. A Residents Affected - Few manual wheelchair was used for mobility. No days of Therapy Services or Restorative Nursing was received

during the assessment period.

The resident's clinical record lacked a care plan for restorative care or services to maintain or improve range of motion.

A Physical Therapy Discharge Summary, dated 10/4/24, indicated Resident 73 was discharged from physical therapy as he had reached maximum potential with skilled services. Discharge recommendations included

the Restorative Nursing Program for passive range of motion and was set up with Restorative Aide 10, who was trained to perform these services.

A Therapy Discharge Recommendation form, dated 10/4/24, indicated Resident 73's restorative nursing recommendations included passive range of motion. This included one set of 20 repetitions of slow motion secondary to spasticity.

A Physiatry progress note, dated 10/8/24 at 3:44 p.m., indicated the resident's current functional status as of 10/8/24 was minimal staff assistance for bed mobility tasks, minimal to moderate assistance from staff was needed for both transfers and toileting using a slide board, minimal assistance from staff was needed for upper body dressing, and maximal assistance was needed for lower body dressing.

A Nurse's Note, dated 10/21/24 at 1:27 p.m., indicated the nurse received a new order to increase the baclofen for muscle spasms.

A Nurse's Note, dated 11/11/24 at 2:22 p.m., indicated the resident complained of an increase in spasms that were painful. The resident's spouse was aware of the clinical situation because the resident was not wanting to get up to get weighed.

The clinical record lacked indication of restorative services being provided to the resident.

During an interview on 1/13/25 at 11:52 a.m., Restorative Aide 15 indicated she and Restorative Aide 10 were assigned to all the residents who were required to receive Restorative Nursing Services. They typically worked with each resident in 15 minute increments each day. Depending on the order, they may be worked with twice daily. This was documented in the clinical record under restorative each time it was completed.

These were the Restorative Aides' primary duties each day. Restorative Aide 15 indicated she had never been assigned to provide Resident 73 restorative care.

During an interview on 1/13/25 at 5:05 p.m., the Physical Therapist indicated she was familiar with Resident 73. The resident had spoken with her when he was discharged from physical therapy regarding a desire to get restorative care/passive range of motion for his lower extremities. She had completed the Therapy Discharge Recommendation form and gave it to the Rehabilitation Director at that time. The form was dated 10/4/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During an interview on 1/13/25 at 5:09 p.m., the Rehabilitation Director indicated a copy of the resident's Therapy Discharge Recommendation form was given to the previous MDS Coordinator (who was no longer Level of Harm - Minimal harm or employed at the facility) on the date she received it from the therapy staff. The MDS Coordinator was potential for actual harm responsible for the assignment of the residents to a Restorative Aide for initiation of the recommendations. A new MDS Coordinator had started since that time. Residents Affected - Few

During an interview on 1/13/25 at 5:14 p.m., the MDS Coordinator indicated Resident 73 was not on her list of residents assigned to receive restorative care. She indicated the resident's chart lacked any tabs for restorative care where the care should have been documented. She had not been provided a copy of the resident's Therapy Discharge Recommendation form, as this occurred prior to her employment.

During an interview on 1/13/25 at 5:22 p.m., the DON indicated the resident had not received restorative care. Therapy recommendations should have been initiated by the previous MDS Coordinator, but was not done.

During an interview on 1/14/25 at 12:00 p.m., Restorative Aide 10 indicated she had never provided Resident 73 restorative care because he was not assigned by the MDS Coordinator. The resident was at risk for a decrease in range of motion and contractures due to his paraplegia.

A current facility policy, revised 3/2022, titled RESTORATIVE/ADL NURSING, provided by the DON on 1/13/25 at 5:29 p.m., indicated the following: .It is the policy of this facility to ensure that a resident without limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates it is unavoidable; A resident with limited range of motion receives appropriate treatment and services to prevent further decline; and A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a decline is unavoidable

3.1-42(a)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 45122

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide supervision for a cognitively impaired resident with a history of falls to prevent repeated falls for 1 of 2 residents reviewed for accidents. (Resident 129)

Findings include:

During an observation, on 1/7/25 at 1:19 p.m., Resident 129 was lying in a bed in the low position with a tall mat beside his bed. The resident was awake and watching television.

During an observation, on 1/8/24 at 11:53 a.m., Resident 129 was assisted in his wheelchair to his room. He declined to get into bed. He had a brace on his right wrist.

During an observation, on 1/9/24 at 2:48 p.m., Resident 129 was lying in bed, turned onto his left side. A tall mat was beside his bed.

During an observation, on 1/10/24 at 3:50 p.m., Resident 129 was lying in bed holding and looking at his remote control. The tall mat was beside his bed. He was had his oxygen on per nasal cannula.

During an observation, on 1/13/24 at 3:07 p.m., Resident 129 self-propelled his wheelchair out of the dining/activity area. He wore nonskid socks and an oxygen cannula. He held a package of candy bars, a package of chips, and a can of soda he had won at BINGO.

Resident 129's clinical record was reviewed on 1/9/25 at 8:53 a.m. Diagnoses included repeated falls, syncope (fainting) and collapse, hypoxemia (low concentration of oxygen in blood), muscle weakness (generalized), difficulty in walking, other lack of coordination, history of falling, unspecified mood (affective) disorder, and altered mental status.

Current physician orders included the following: divalproex 125 milligrams (mg) twice a day for mood stabilization (12/23/24), hydrocodone-acetaminophen 10-325 mg every six hours as needed for pain (12/12/24), check function and placement of silent pressure alarm to bed and chair/wheelchair every shift for safety (12/17/24), and keep splint clean and dry until follow up with orthopedic physician and check skin each shift to monitor for break down for radial fracture (12/23/24).

An admission Minimum Data Set (MDS) assessment, dated 12/14/24, indicated Resident 129 was severely cognitively impaired. He had hallucinations and rejected care one to three days of the assessment period. He had limitations of his functional range of motion to his upper and lower extremities on both sides. He required substantial to maximal assistance with toileting, bathing, dressing, putting on and taking off footwear, rolling left and right in bed, moving from sitting to lying, moving from lying to sitting, moving from sitting to standing, transferring from chair to bed and bed to chair, and transferring to the toilet. He was short of breath with exertion and when lying flat. He had fallen the month prior to admission. He had fallen two or more times with no injuries and one time with injury since he was admitted . A bed alarm was used daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A current care plan for falls indicated the resident was at risk for falls related to history of falls, syncope, and decrease in safety awareness (initiated 12/17/24 and revised on 1/8/24). Interventions included the following: Level of Harm - Minimal harm or A silent pressure chair/bed alarm was to be used to alert staff that the resident needed staff assistance with potential for actual harm transfers (initiated 12/17/24 and revised 1/8/25); The resident was to wear proper footwear or non-slip footwear when he is up (initiated 12/17/24); The resident will have a non-slip mat in his wheelchair to Residents Affected - Few decrease the resident from sliding out of his wheelchair (initiated 12/17/24); The resident will sleep/rest in a floor bed that is low to the floor with a mat on the floor to assist in decreasing the risk of the resident injuring himself when he rolls out of bed (initiated 12/17/24); The resident will be toileted at 7:00 p.m. as he allows (initiated 12/18/24); and The resident will be reminded to change position slowly (initiated 12/22/24).

An admission evaluation, dated 12/12/24 at 7:34 p.m., indicated the resident had fallen in the last month and two to six months prior to admission. He had a fracture related to a fall in the six months prior to admission.

A fall risk assessment, dated 12/12/24 at 7:37 p.m., indicated the resident had intermittent confusion. He had three or more falls in the past three months. He was chair bound and/or required assistance with elimination.

He received three to four medications which increased the risk of falling. He had three or more predisposing conditions which increased the risk of falling. He was a high fall risk.

A Hospital Emergency Department Progress Note, dated 12/22/24 at 6:58 a.m., indicated the resident presented to the emergency department by ambulance. The resident reported he was sitting in a chair and was asleep. He was unsure what had happened. The staff reported he fell forward out of his chair and hit his head. He sustained a large laceration to his forehead. His right forearm had tenderness with flexion and extension of the wrist. On the right side of the forehead just below the hairline was an approximately 2.5 centimeter (cm) irregular laceration that was y-shaped with an additional linear portion extending from the center gaping, bleeding controlled. The laceration was repaired with five sutures. The x-ray showed a distal radius (bone in the forearm) fracture and possible scaphoid (small bone in the wrist) fracture. The orthopedic physician was consulted about the x-ray findings and a follow-up was advised. A splint was applied to the right upper extremity. The resident was discharged back to the facility.

An x-ray of the right wrist, dated 12/22/24 at 8:48 a.m., indicated an avulsion (a break in a small piece of bone in the wrist that's attached to a ligament or tendon) fracture arising from the volar (palm side) aspect of

the wrist and a lucency (darker area on the X-ray) through the scaphoid which may represent a nondisplaced fracture.

The resident's fall events and immediate interventions were as follows:

A Nurses Note and Fall Investigation Worksheet, dated 12/13/24 for the fall at 5:40 a.m., indicated the resident was found lying on his right side on the floor next to his bed with his head near the foot of the bed.

The resident's feet were bare. The call light was not sounding. The resident complained of some soreness to back and leg. No obvious injuries were noted. The immediate intervention was the placement of a bed alarm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A Nurses Note and Fall Investigation Worksheet, dated 12/13/24 for the fall at 8:00 p.m., indicated the resident was found on both knees on the floor in his room. The resident had appeared to attempt to Level of Harm - Minimal harm or self-transfer from wheelchair. He wore gripper socks. His call light was sounding. An alarm was being used potential for actual harm at the time of the fall and was working properly. No new injuries were noted. The immediate intervention was

the placement of a chair alarm pad underneath the resident. The resident was assisted into the wheelchair, Residents Affected - Few and the call light was clipped to his shirt. He was reminded to use the call light if he wished to move.

A Nurses Note and Fall Investigation Worksheet, dated 12/14/24 at 7:00 a.m., indicated the resident was found sitting on the floor at the side of the bed with his back resting against the bed and his legs extended in front of him. The resident indicated he was sitting on the bed at the time of the fall. The bed was in low position. The resident had one gripper sock on and one was off on the floor beside him. The bed alarm was

in place and sounded. The call light was not sounding. No new injuries were noted. The immediate intervention was the placement of the bed in a low position with a mat at the side of the bed. The resident was also assisted back to bed, and his gripper socks were reapplied.

A Nurses Note and Fall Investigation Worksheet, dated 12/14/24 at 9:00 p.m., indicated the resident was sitting in a wheelchair at the nurses station. The resident leaned forward and grabbed at the floor. He fell out of the chair onto his side. The wheelchair brakes were locked. The resident had gripper socks on both feet.

The chair alarm was in place and sounded after the fall. A skin tear to the resident's right hand was measured at 1.8 cm by 0.2 cm. The immediate intervention was the placement of the nonslip mat in the wheelchair under the cushion. The skin tear was cleansed and dressed.

A Nurses Note and Fall Investigation Worksheet, dated 12/18/24 for the fall at 7:30 p.m., indicated the resident attempted to stand up and fell on to his left side in front of the nurses station. An alarm was in place and working. The immediate intervention was the toileting of the resident and assisting him to bed.

A Nurses Note and Fall Investigation Worksheet, dated 12/22/24 at 5:50 a.m., indicated the nurse was standing at the medication cart when the resident fell forward without warning and hit his head on the floor. Pressure was applied to his wound, and his neck was stabilized. He transferred to the hospital. He had a one-inch laceration on his forehead. The resident wore gripper socks. The chair alarm was in place and working properly.

A Nurses Note, dated 12/22/24 at 3:15 p.m., indicated the resident returned from the hospital with a laceration to his forehead, an abrasion of his right arm, a distal radius fracture, and lumbar radiculopathy (condition where a nerve in the spine is damaged or irritated). Sutures were intact to his forehead and open to air.

A Fall IDT (interdisciplinary team) Note, dated 12/24/24 at 1:16 p.m., indicated Resident 129 was seated in a wheelchair at the nurses station when staff witnessed the resident falling forward from the wheelchair. Staff was unable to intervene. The immediate intervention for the fall on 12/22/24 at 5:50 a.m., was to remind the resident to change positions slowly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview, on 1/14/25 at 11:52 a.m., QMA 13 indicated the interventions to prevent falls for the resident were his chair alarm, a bed alarm, a mat beside his bed, and he was taken to the bathroom every Level of Harm - Minimal harm or two hours even though he had a catheter. The resident was generally up and about in the sight of staff. potential for actual harm

During an interview, on 1/14/25 at 12:28 p.m., LPN 19 indicated interventions to prevent falls for the resident Residents Affected - Few included his bedside mat. She indicated she needed to access his care plan. Then, she indicated bed and chair pads that alarmed at the nurses station were used. He also did not stand well and required nonskid footwear. He had a nonslip mat in his wheelchair. He was to be toileted at 7:00 p.m. The staff also monitored him. She indicated whenever she went up and down the hall she looked in every room.

During an interview, on 1/14/25 at 12:41 p.m., CNA 20 indicated interventions to prevent falls for the resident included a tall mat beside his bed, a bed alarm, a chair alarm in his wheelchair, gripper socks or shoes on, and his call light should be in reach. She could look at the Kardex (list of care strategies in the clinical record) if she needed more information.

During an interview, on 1/14/25 at 3:08 p.m., the DON indicated they tried to do all kinds of things to prevent

the resident from falling like bringing him to the nurses station. Since one of his resident representatives had returned to town and visited frequently, he had been doing much better.

During an interview, on 1/14/25 at 4:17 p.m., the DON indicated the pressure alarms should not be used in place of supervision for the residents. She did not have documentation of increased supervision or additional interventions that would show increased supervision for the resident.

A current facility policy, revised 10/8/24, titled Accidents and Supervision, provided by the DON on 1/13/25 at 4:28 p.m., indicated the following: Policy: The resident environment will remain free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary

3.1-45(a)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Level of Harm - Minimal harm or 45122 potential for actual harm Based on interview and record review, facility failed to ensure the physician was notified of a resident's Residents Affected - Few significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 72)

Findings include:

Resident 72's clinical record was reviewed on 1/10/25 at 8:56 a.m. Diagnoses included Alzheimer's disease, dysphagia, oropharyngeal phase (swallowing difficulty that occurs in the mouth and throat), and other recurrent depressive disorders.

Current physician's orders included regular diet, mechanical soft texture with ground meat and thin consistency liquids (7/31/24), super cereal (fortified food supplement) at breakfast (8/13/24), and magic cup (vitamin and mineral rich food supplement) at lunch (9/3/24).

A Minimum Data Set (MDS) assessment on 12/14/24 indicated the resident was severely cognitively impaired. The staff assessment of her mood indicated the resident had poor appetite or overeating for two to six days of the assessment period. She required partial to moderate assistance with eating.

The resident's weights were as follows:

7/30/24 - 107.4 pounds

11/25/24 - 99.2 pounds

12/16/24 - 101.6 pounds

12/23/24 - 101.3 pounds

12/30/24 - 92.5 pounds

1/6/25 - 95.7 pounds

1/13/25 - 96.3 pounds

The resident experienced an 8.69% weight loss in one week from 12/23/24 to 12/30/24. She experienced a 6. 75% weight loss in one month from 11/25/24 to 12/30/24. From 7/30/24 to 1/13/25, nearly a six-month span,

she experienced a 10.24% weight loss.

The clinical record lacked notification of the physician or the resident representative of the resident's significant weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 155432 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155432 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Albany Health Care & Rehabilitation Center 910 W Walnut St Albany, IN 47320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0710 During an interview, on 1/14/25 at 11:20 a.m., LPN 17, the charge nurse on the resident's unit, indicated when a resident had a significant weight loss or gain, the physician and family were notified. Notifications Level of Harm - Minimal harm or were documented in the progress notes. The staff, typically, reweighed a resident when a significant change potential for actual harm in weight occurs to ensure the weight was correct. The aides reported to the nurses when they obtained the residents' weights. She thought the resident might have been followed by the nutritional at risk (NAR) team. Residents Affected - Few The aides had not told LPN 17 of the resident's weight loss, and she indicated they most likely told the NAR team. She had been unaware of the resident's weight loss.

During an interview, on 1/14/25 at 11:29 a.m., RN 18 who was the unit manager and part of the NAR team, indicated the resident was not currently on the NAR list. She did not know the resident had experienced significant weight loss. She indicated the dietician should have notified the NAR team when the weight was put into the electronic medical record as the software triggered an alert with a significant weight loss or gain.

She found where the weight loss had triggered the alert. She was unable to find where the physician had been notified.

During an interview, on 1/14/25 at 12:00 p.m., the DON indicated the physician should have been notified of

the resident's significant weight loss.

A current facility policy, revised on 2/2022, titled PHYSICIAN/CLINICAN/FAMILY/RESPONSIBLE PARTY NOTIFICATION FOR CHANGE IN CONDITION, provided by the DON on 1/14/25 at 12:08 p.m., indicated

the following: .The facility must immediately inform the resident; consult with the resident's physician/clinician; and notify, consistent with his or her authority, the resident representative when there is .

a significant change in the resident's physical, mental, or psychosocial status

3.1-22(b)(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 155432