Albemarle Health & Rehabilitation Center

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wander guard for safety reasons. During an interview on 10/21/2025 at 2:40 PM, the MDS Coordinator stated Resident #127's MDS with an ARD of 04/28/2025 was not completed accurately and should have indicated the presence of wandering in the past one to three days. During an interview on 10/23/2025 at 10:07 AM, the Staff Development Coordinator/Infection Preventionist, who assumed the role of the Director of Nursing as of 10/16/2025, stated Resident #127's MDS was not accurate for wandering and she expected the MDS to be accurate and for staff to follow the RAI manual. During an interview on 10/23/2025 at 11:56 AM, the Administrator stated she expected the MDS to be accurate and for staff to follow the RAI manual.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Albemarle Health & Rehabilitation Center

1540 Founders Place Charlottesville, VA 22902

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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident displayed exit-seeking behavior. During a follow interview on 10/23/2025 at 10:07 AM, the SDC/IP stated an elopement risk assessment should be completed when a resident admitted to the resident, quarterly, and as-needed. When asked what was meant by as-needed, the SDC/IP, stated if an assessment was incorrect. During a follow-up interview on 10/23/2025 at 11:56 AM, the Administrator stated she expected staff to complete an elopement risk assessment when the resident admitted to the facility, quarterly, and whenever the resident had exit-seeking behaviors. The facility submitted a removal plan that was accepted by the state survey agency on 10/23/2025 at 11:20 PM. The removal plan indicated the following: F-F689 Accidents and Hazards Removal Plan1. Plan Corrective Action for those residents found to be affected by the deficient practice:Resident #127 was placed on 1:1 supervision to ensure safety and to not leave the building unattended once returned to the building on 05/11/2025. Resident #127 was evaluated by nursing staff with no new impairments on 05/11/2025 and seen by the nurse practitioner (NP)

on 05/12/2025. Resident remained on 1:1 supervision and discharged from the facility on 05/20/2025.

Resident #133 was placed on 1:1 supervision as a precaution on 10/20/2025. The [wander guard] was placed back on the resident and secured the same day it was observed to be off on 10/17/2025. admission

Record for Resident #133 was placed in the elopement binder at the front desk on 10/19/2025, all other binders on the units were already updated. 2. Corrective Actions taken for residents with potential to be affected by deficient practice:All residents who are at risk of elopement have the potential to be affected by

this deficient practice. The facility licensed nursing staff will conduct new elopement assessments on all residents to determine elopement risk on 10/23/2025 with follow-up based on findings. Any newly identified residents will be assessed for a [wander guard] by Director of Nursing, and it will be placed appropriately.

The order and

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Albemarle Health & Rehabilitation Center

1540 Founders Place Charlottesville, VA 22902

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure ordered medication was available for administration for 1 (Resident #128) of 1 sampled resident reviewed for change of condition. Findings included: A facility policy titled, General Guidelines for Medication Administration, revised 08/2020, indicated The facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Resident #128's Admission/readmission Nursing Collection Tool V15-V2, indicated the facility admitted the resident on 08/01/2021 with a medical history to include a diagnosis of alcoholic cirrhosis. Resident #128's Order Summary Report revealed an order dated 08/01/2025, for gabapentin (a prescription medication used to treat nerve pain) capsule, 100 milligrams by mouth three times a day for alcoholic cirrhosis of liver and an order dated 08/01/2025, for sucralfate (a prescription medication used to treat ulcers) oral tablet, 1 gram give one tablet by mouth two times a day for alcoholic cirrhosis of liver. Resident #128's Care Plan Report, included a focus area initiated 08/01/2025, that indicated the resident was at risk for pain. Interventions directed staff to administer medications as ordered (initiated 08/01/2025) and observe for physical indicators of pain (initiated 08/01/2025). Resident #128's Medication Administration Record [MAR] for the timeframe 08/01/2025 - 08/31/2025, revealed no evidence to indicate the 9:00 PM dose of gabapentin and sucralfate for 08/01/2025 was administered to the resident. Per the MAR, Licensed Practical Nurse (LPN) #15 documented on the MAR a 9 for the administration of the 08/01/2025 9:00 PM dose of gabapentin and sucralfate, which indicated Other / See Progress Notes. Resident #128's progress notes for the timeframe 07/24/2025 to 08/23/2025, revealed no evidence to indicate why the 08/01/2025 9:00 PM dose of gabapentin and sucralfate were not administered to the resident. The pharmacy Delivery Manifest dated 08/02/2025 at 10:18 AM, revealed gabapentin and sucralfate were delivered to the facility from the pharmacy and signed by an LPN on 08/02/2025 at 10:04 AM. On 09/24/2025 at 12:02 PM and 09/25/2025 at 12:16 PM, a telephone interview was attempted with LPN #15, an agency nurse; however, there was no answer, and the surveyor was unable to leave a message. During an interview on 09/24/2025 at 12:06 PM,

the Director of Nursing (DON) stated the pharmacy delivered medications to the facility between 11:00 PM and 12:00 midnight and the next delivery time would be the next morning. The DON stated Resident #128 arrived at the facility around 2:00 PM on 08/01/2025 and most of the resident's medications were not due to be administered until 08/02/2025. During an interview on 09/26/2025 at 11:47 AM, LPN #14 stated the facility had an automated medication management system that contained gabapentin; however, a lot of the agency nurses did not have access to the system. During an interview on 09/25/2025 at 2:50 PM, the Regional Director of Clinical Services stated that per her conversation with the pharmacy, no medication was ever pulled for the facility's automated medication management system for Resident #128.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Albemarle Health & Rehabilitation Center

1540 Founders Place Charlottesville, VA 22902

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 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and document review, the administrative staff failed to conduct a thorough investigation into the elopement of Resident #127 from the facility on 05/11/2025. This deficient practice affected 1 (Resident #127) of 4 sampled residents reviewed for accidents.Findings included: The Job Description for

the Administrator revised 04/2023, indicated The Administrator is directly responsible for the overall successful operations of the healthcare center. The primary role of the Administrator is to plan, direct and lead the day-to-day functions of the facility in accordance with current, federal, state, and local standards, guidelines, and regulations that govern skilled nursing facilities to ensure that residents are consistently receiving care and services in line with the company's vision of Care Beyond Care. The Job Description for

the Director of Nursing (DON) revised 05/2023, indicated The Director of Nursing is responsible for the overall management, supervision, and direction of the nursing services department. The DON implements and maintains nursing department goals and objectives, ensures compliance with current standards of nursing practice, company policy and procedure, as well as applicable federal, state, and local guidelines and regulations. On 05/11/2025 at 8:55 PM, Resident #127, identified by the facility as having exit-seeking behaviors, eloped from the facility without staff knowledge. Licensed Practical Nurse (LPN) #20, assigned to the care of the resident, failed to ensure the facility's missing person protocol (Code Orange) was implemented as specified. Per facility documents, the Administrator was not made aware of the resident's elopement until 10:48 PM on 05/11/2025. The facility staff failed to notify the resident's responsible party that the resident was missing. On 05/11/2025 at 11:08 PM, the resident used their cell phone and called a family member and reported they were at a baseball game, cold, and needed to be picked up. The resident's responsible party then notified the facility staff of the resident's whereabouts, and the resident was returned to the facility by the local police and a staff member. The facility's investigation file only contained a statement from LPN #20; there were no other interviews with the staff that were on duty at the time of the resident elopement or interviews with the staff that participated in the search for the resident.

Refer to F-F689. During an interview on 10/18/2025 at 3:54 PM, the Administrator stated from a review of the facility's investigation, LPN #20 enacted the Code Orange and no other staff were interviewed during the investigation of Resident #127's elopement from the facility. The Administrator stated possibly more interviews were needed and should have been conducted. During a follow-up interview on 10/20/2025 at 10:26 AM, the Administrator stated her expectation for the investigation was that a root cause analysis was determined so that the facility would know where the break down in the process was not followed. The Administrator stated she expected there should have been interviews with all the staff that worked and everyone who participated in the Code Orange.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Albemarle Health & Rehabilitation Center

1540 Founders Place Charlottesville, VA 22902

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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

committee. The Administrator stated she did not know why it was not reviewed in QAPI, but it should have been. During a follow-up interview on 10/25/2025 at 10:52 AM, the Administrator stated her expectation was that the QAPI committee should have reviewed Resident #127's elopement. She stated if it had been reviewed by QAPI, they could have conducted a root cause analysis to determine if there were processes that were broken; identified additional steps the facility needed to take, such as staff training; and determined whether a Performance Improvement Plan (PIP) needed to be developed.

Event ID:

Facility ID:

If continuation sheet