Anberry Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for five of nine sampled residents (Residents 7, 8, 52, 63, and 92) when the Controlled Substance Record (CSR) and the Controlled Drug Record (CDR) (a mandatory document used for tracking drugs from the moment they arrive at a facility until they are given to a patient or destroyed, acting as a security measure to prevent theft or misuse) were not completed by the Licensed Nurses upon receipt from the pharmacy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when:A pot with food and debris in it was stored in the clean area. A black bean veggie patty bag with one patty in it, in the walk-in freezer, was open and undated. The walk-in freezer fan had ice buildup on it. A plastic container in the walk-in refrigerator with sliced pink fruit inside was unlabeled and undated. A box of mushrooms and a box of celery was open and exposed to air in the walk-in refrigerator. Mushrooms and white liquid were observed on the walk-in refrigerator floor. The sanitizer spray bottle used for cleaning food countertops, contained water in it instead of the sanitizer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when:The food preparation sink did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 2. The ice machine that supplies ice to the residents in the facility did not have an air gap. These failures had the potential to contaminate food sources for 90 of 97 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death.

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 10) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not attempt or implement behavior monitoring for Resident 10's use of haloperidol (medications used to treat schizophrenia [a mental illness that is characterized by disturbances in thoughts]). This failure placed Resident 10 at risk for experiencing adverse effects from receiving medication without behavior monitoring. During a concurrent observation and interview on 1/20/26 at 2:45 p.m. Resident 10 was observed ambulating in the hallway using a front wheel walker, walked to the activity room and joined group activities other residents. [...]

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of five sampled residents (Resident 2) when Resident 2 did not have a care plan for a diagnosis of dementia (a progressive state of decline in mental abilities). This failure placed Resident 2 at risk for harm by not identifying and monitoring signs and symptoms and care of resident with dementia. During a concurrent observation and interview on 1/20/26 at 10:15 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain professional standards of practice for one of six sampled residents (Resident 48) when Resident 48's physician's orders had directions to give a total dosage of 150 milligrams (mg- a unit of measurement) of clozapine (medication used for reducing hallucinations, delusions, and risk of suicide) when Resident 48 was prescribed 175 mg. This failure had the potential to cause Resident 48 to receive less medication than what was prescribed.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure residents who were not able to carry out activities of daily living (ADLs- routine tasks/activities a person perform daily to care for themselves) were provided assistance to maintain personal hygiene and grooming for two of five sampled residents (Resident 4 and 56) when Resident 4 and Resident 56 had fingernails that were long, jagged and had colored particles under their fingernails. These failures resulted in poor personal hygiene and had the potential to result in serious health condition for Resident 4 and Resident 56. During a concurrent observation and interview on 1/20/26 at 10:45 a.m. during initial tour in Resident 56s room, Resident 56 was observed lying in bed with the TV on. [...]

Inspectors wroteBased on observation interview and record review the facility failed to ensure residents were free from unnecessary drugs for one of three sampled residents (Resident 1) when Resident 1 was prescribed and received an antipsychotic medication (Quetiapine-used for the treatment of mental illness) with a black box warning (serious warning from the FDA that appears on medication label indicating it has a significant risk or life threatening increased mortality in elderly patients with dementia related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death), for the treatment of Dementia (brain disorder that affects the ability to remember) with documented behaviors of restlessness, inability to sleep and voiced sadness on 2/11/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when on 10/23/24, Resident 1 eloped (leaves a facility without supervision or permission and may be a danger to themselves or others) from his bedroom through the sliding door that should have been securely locked in place. This failure resulted in Resident 1 allegedly removing the sliding door lock, opening the sliding door and eloped from the facility, resulting in Resident 1 ' s emergency room visit on 10/24/24.

Inspectors wroteBased on observation interview and record review the facility failed to provide a safe environment for one of three sampled residents (Resident 1), when on 10/23/24, Resident 1 eloped (leaves a facility without supervision or permission and may be a danger to themselves or others) from his bedroom through the sliding door that should have been securely locked in place. This failure resulted in Resident 1 allegedly removing the sliding door lock, opening the sliding door and eloped from the facility, resulting in Resident 1's emergency room visit on 10/24/24.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure staff performed hand hygiene during wound care for 1 (Resident #55)of 1 sampled resident reviewed for pressure ulcer/injury.

Inspectors wroteBased on interview and record review, the facility failed to meet the minimum requirement of a registered nurse on duty for eight consecutive hours per day, seven days per week when a registered nurse was not on duty for the minimum eight consecutive hours per day for six of 30 days sampled. This failure had the potential to result in residents not receiving services required to be provided by an RN.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety for 91 residents when: 1. There was expired food in the refrigerators and freezer available for resident consumption. 2. Food items in the dry storage area were open and past the use by date. 3. Two kitchen staff members failed to properly cover facial hair while they performed kitchen duties. These failures had the potential for unsafe food handling in a highly susceptible resident population.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications stored in the Central Supply Room were disposed of after the expiration date was reached. This failure had the potential to place ninety-one residents at risk of receiving expired medications.

Inspectors wroteBased on interview and record review, the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN-a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume responsibility) and Notice of Medicare Provided Non-Coverage (NOMNC) for one of three sampled residents (Resident 57) when the Medicare coverage was terminated. This deficient practice resulted in not protecting Resident 57's (and the resident representative) right to appeal the termination of Medicare Part A and possibly denying Resident 57 needed services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for one of three sampled residents (Resident 45), when Resident 45 did not have a care plan for his customary routines and activities. This failure had the potential to result in Resident 45's activity needs to go unmet.

Inspectors wroteBased on interview, and record review, the facility failed to revise a person centered comprehensive care plan in a timely manner for one of three sampled residents (Resident 87) when Resident 87's care plan did not accurately reflect the current physician's ordered settings for Resident 87's Bi-Pap machine (Bi-level Positive Airway Pressure-a machine used to provide a non-invasive form of therapy for patients suffering from obstructive sleep apnea- OSA a potentially serious sleep disorder in which breathing repeatedly stops and starts.). This failure had the potential to result in respiratory complications and failure for Resident 87.

Inspectors wroteBased on interview and record review the facility failed to timely notify the ordering physician for a laboratory result that fell outside of the normal reference range for one of two sampled residents (Resident 65) when Resident 65's urinalysis (UA-urine sampled to test for the presence of bacteria) result was positive for bacteria that was resistant to the physician ordered antibiotic (a medication to treat infections) regimen. This failure resulted in the administration of antibiotic treatment to Resident 65 that she was resistant to from 1/18/2020 through 1/25/2020 and placed her at risk for further complications from the Urinary Tract Infection (UTI).

Inspectors wroteBased on observation, staff interview and document review, the facility failed to ensure the nutritional needs were met for residents on a small portions diet when the lunch meal on 3/9/2020 was not plated in accordance with menu guidance for one of two sampled residents (Resident 34). This failure had the potential to result in weight gain, further compromising the medical status.