Anberry Post Acute

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 2Based on observation, interview, and record review, the facility failed to provide needed care and services in accordance with professional standards of practice for two of six sampled residents (Resident 25 and Resident 74) when Resident 25 and Resident 74's fingernails and toenails were thick, long and had jagged edges. These failures placed Resident 25 and Resident 74 to experience discomfort and pain when wearing footwear and risk of skin breakdown which could lead to skin infection. During a concurrent observation and interview of 6/16/26 at 11:24 a.m. during initial tour in Resident 74's room, Resident 74 was observed sitting up in his wheelchair at bedside. Resident 74 observed fingernails and toenails thick, long with jagged edges. Resident 74 stated he did not remember the last time his nails were cut. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services were being met according to facility's policy and procedures when:1. Emergency medication kit was opened on 4/13/26 and had not been replaced by the pharmacy for over two months. This failure resulted in medication not being available in the e-kit (emergency medication container) and had the potential not to meet the needs of the residents during emergencies.2. Resident 75's medication brought by the family was not verified by the facility's licensed pharmacist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications used were labeled and stored in accordance with professional standards when:1. A [Brand name] topical gel ointment (a topical gel ointment for external use only to relieve joint pain, stiffness and swelling 1.7 oz [ounce - unit of measurement]) with no medication label and no opened date was stored with other liquid and oral medication in front medication cart 300. This failure had the potential for cross contamination (a transfer of harmful bacteria from one object to another) and improper storage of medication.2. Resident 122's [Brand name] Ophthalmic Solution (an eye drops to lubricate, soothe dry burning or irritated eyes) had no open date and no used by date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for three of seven sampled residents (Residents 21, 97, and 8) when:1. Licensed Vocational Nurse (LVN) 5 did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers to protect residents and themselves from potential infectious hazards) when LVN 5 accessed Resident 21's gastrostomy tube (GT, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) on 6/16/26. Resident 21 was on enhanced barrier precaution (EBP- measures used in healthcare settings to prevent the spread of infections) due to presence of GT. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop a baseline care plan for one of seven residents (Resident 97) when Resident 97 did not have a baseline care plan initiated within 48 hours of admission on [DATE] for end stage renal disease (ESRD -a condition where the kidneys can no longer function and hemodialysis treatment (a medical treatment that uses a machine to clean a person's blood by removing waste products and excess water). This failure had the potential to result in Resident 97's hemodialysis needs to go unmet, which placed Resident 97 at risk for complications associated with ESRD which could compromise Resident 97's overall health.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for one of seven sampled residents (Resident 3) when Resident 3 did not have a comprehensive CP implemented for Resident 3's depression medication. This failure had the potential for Resident 3's medication side effects and adverse reactions to go unnoticed and undetected by nursing staff. [...]

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 2Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for two of five sampled residents (Resident 9 and Resident 25) when Licensed Vocational Nurse (LVN) 1 and LVN 3 did not follow physician order to administer Apixaban (medication used to prevent and treat blood clots) medication with food to Resident 9 and Resident 25 during medication pass on 6/18/26. These failures to follow proper medication administration had the potential to result in reduced effectiveness of treatment or harm to Resident 9 and Resident 25. During a concurrent observation and interview on 6/18/26 at 7:53 a.m. with LVN 1 outside of Resident 25's room, LVN 1 observed preparing Resident 25's medications including Apixaban. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the administration of enteral nutrition (delivers specialized liquid formulas directly to the stomach) was consistent with physician's orders for one of seven sampled residents (Resident 21) when Resident 21's enteral nutrition was administered by Licensed Vocational Nurse (LVN) 5 for almost three hours past the prescribed time of administration on 6/16/26. Resident 21 was NPO (nothing by mouth). This failure resulted in Resident 21 receiving her enteral feeding (also referred to as tube feeding is the delivery of nutrients through a feeding tube directly into the stomach) late and had the potential risk of receiving inadequate nutrition and experience unrecognized decline in health conditions which could compromise Resident 21's overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary respiratory care consistent with professional standards of practice was provided for one of seven sampled residents (Resident 92) when there was no physician's order for Resident 92's use of continuous positive airway pressure (CPAP -a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure), a comprehensive person-centered care plan was not developed and implemented and the CPAP was not being routinely cleaned by the facility staff. Resident 92 had a diagnosis of Sleep Apnea (a condition that makes you stop breathing while you're sleeping). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's entire medication regimen was monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for three of ten sampled residents (Resident 8, Resident 2 and Resident 24) when:1. Resident 8 was not being monitored for anticoagulant (medication that prevents blood clots from forming) side effects as indicated on Resident 8's care plan. Resident 8 was receiving Rivaroxaban (a blood thinner that treats or prevents blood clots) for Deep Vein Thrombosis (DVT) prophylaxis preventive measures used to stop the formation of dangerous blood clots in deep veins, primarily in the legs) and Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when:1. A box of zucchini was not labelled and dated in the walk-in refrigerator.2. Station 200's nourishment unit refrigerator was observed with a box of pizza brought into the facility that was not properly labeled with the resident's name, room number, date the food was brought in, opened or the use-by date. These failures had the potential for staff to have access to expired foods for residents.1. During concurrent observation and interview on 6/16/26 at 9:31 a.m. with the Kitchen [NAME] (KC) inside the walk-in refrigerator, an unlabeled and undated plastic bin containing zucchini was observed on a metal rack. KC stated all food items inside should be labeled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records of residents that are complete and accurately documented in accordance with accepted professional standards and practice for two of 10 sampled residents (Resident 11 and Resident 9) when:1. Resident 11's electronic health record (EHR) contained no documentation of completed ileostomy (a specific type of surgery where the lower part of the small intestine is brought through an opening in the belly to form a stoma [an artificial opening made by a surgeon on the abdomen-belly]) bag changes since 7/3/25. This failure had the potential to disrupt continuity of care, create gaps in the services provided, and lead to miscommunication among staff regarding Resident 11's status.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to educate and offer Covid-19 vaccinations for three of three sampled employees (Certified Nurse Assistant [CNA] 5, CNA 7, and Licensed Vocational Nurse [LVN] 5) when CNA 5, 7, and LVN 5's employee files were reviewed and did not contain documentation that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccinations or if they were offered the COVID-19 vaccination. This failure had the potential to increase the risk to vulnerable nursing home residents by potentially exposing them to outbreaks and raising the likelihood of severe illness or death. During an interview on 6/19/26 at 9:50 a.m. with the Infection Preventionist (IP), the IP stated the facility did not offer Covid 19 vaccinations for staff because it was no longer mandated for staff to be vaccinated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, and sanitary condition was maintained when four containers (five gallon each) containing chemicals in the dirty area of the laundry room were found covered with thick white foamy substance and the floor directly below the containers also contained the thick white foamy substance. This failure had the potential to affect the health condition of the 105 residents, staff and visitors of the facility, like severe skin burns, eye damage and toxic (poisonous or harmful) respiratory irritation.

Inspectors wroteBased on interview, and record review, the facility failed to meet professional standards of quality for one of three residents (Resident 1) when Resident 1 was admitted with a pressure ulcer (a localized area of skin damage and underlying tissue that develops when prolonged pressure is applied to the body) of the sacral region (the area of the lower back and pelvis) and Resident 1 required to be turned and repositioned every two hours. Resident 1's care plans did not indicate Resident 1 be turned and repositioned every two hours and Resident 1's medical records did not indicate Resident 1 was turned and repositioned every two hours. [...]

Inspectors wroteBased on interview and record review the facility failed to inform and provide written information on how to formulate an advance directive (a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness or injury) for 87 of 87 residents when staff did not document information on how to obtain an advance directive in resident charts. This failure violated the rights of 87 residents to be informed on how to formulate and obtain an advance directive.

Inspectors wroteBased on interview and record review, the facility failed to revise and implement a person-centered comprehensive care plan (CP- road map for the care of a resident and a necessary tool in following the nursing process) for one of eight sampled residents (Resident 45) when the care plan was not updated to reflect discharge from hospice (end of life) service. This failure had the potential for Resident 45's needs to not be meet.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for four of 16 sampled residents (Resident 46, Resident 231, Resident 233, and Resident 235) when: 1. Resident 46, Resident 231 and Resident 235's oxygen tubing were not labled with the date the tubing was changed. This failure put Residents 46, 231 and 235 at risk of infection. 2. The Attending Physician (AP) was not notified when Resident 233's medication for hypertension (high blood pressure) was not given due to low blood pressure levels. This failure put resident 233 at risk of harm due to low blood pressure levels. 3. Resident 235's physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident) for oxygen flow rate was for 2 L/min (liters per minute - a unit of measurement) and it was set at 4.5 L/min. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing staff information data posting contained or demonstrated the total numbers and actual hours worked by Registered nurses (RN), license vocational nurses (LVN) and Certified nurse aides, were posted daily. This failure resulted in 87 out of 87 residents and their family members not being able to identify who was responsible for their care, how many licensed and unlicensed staff were on shift, and the total number of hours staff were working.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable and flavorful food when: 1. Broccoli was bland and without flavor for the regular diet. 79 Residents received broccoli at the facility. 2. Puree salad did not taste good. Five residents (Residents 2, 9, 63, 481, 482) were on the puree diet. These failures resulted in lack of flavor and palatability in vegetables and puree salad which can lead to residents having a decreased food intake and could result in weight loss and further compromise nutritional and medical status. There were 84 residents eating at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and ice were stored, distributed, and served safely when: 1. The ice machine was observed with black spots above the water trough (a compartment within the ice machine where water is stored before it is frozen into ice cubes) and pink residue on the ice grate (a compartment within the ice machine that determines the size of the ice cubes that are produced) and sensor (monitors ice levels) 2. Apple juice pitcher located in the nourishment room refrigerator was dated past the use by date; and 3. The nourishment room refrigerator had dry, sticky substance on bottom drawers and a door shelf. [...]

Inspectors wroteBased on interview and record review the facility failed to notify residents and residents' representatives (RP-person designated to make decisions for a resident) in writing of a resident's transfer to the hospital for four of eight residents (Resident 2, 16, 33, and 41) when the facility did not provide written notice to the resident or their RP when they were transferred to the hospital. This failure violated the rights of Residents 2, 16, 33, and 41 to be informed in writing of the reason for transfer to the hospital.

Inspectors wroteBased on interview and record review the facility failed to provide residents and residents' representatives (RP- a person designated to make decisions for a resident) written information regarding the bed hold policy for four of eight sampled residents (Resident 2, 16, and 41) when no written notices about the facility's bed hold policy was given to residents or their RPs upon the residents' transfer to the hospital. This failure violated the right for residents and RPs to be notified in writing of the facility's bed hold policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for two of 16 residents (Residents 231, and 235) when Resident 231 and Resident 235 did not have care plans for oxygen administration. This failure put Residents 231 and 235 at risk for harm due to improper monitoring, documentation and administration of oxygen use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored and labeled in accordance with currently accepted professional standards of practice when: 1. The refrigerator in section 300-Medroom contained an antibiotic with an unreadable expiration date. Carts 200-Backside and 300-B contained : [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed for 16 Residents (Resident 5, 7, 13, 18, 23, 28, 32, 33, 35, 36, 41, 44, 45, 52, 60, 281) when a dessert was served that was not on the planned and approved menu. This failure had the potential to result in 16 residents having a decreased intake of nutrients and lower satisfaction and interest of the meal as the resident could have been looking forward to receiving the planned and approved dessert menu item.

Inspectors wroteBased on observation, interview, and record review, two of two Licensed Vocational Nurses (LVN 4 and LVN 7) failed to implement and maintain infection control practices to provide a safe and sanitary environment to help prevent the development and transmission of infections when: 1. Licensed Vocational Nurse (LVN) 4 failed to don appropriate Personal Protective Equipment (PPE) prior to entering an isolation room. 2. LVN 7 failed to perform hand hygiene (the cleansing of hands with soap and water, antiseptic hand washes, and antiseptic hand rubs such as alcohol-based hand sanitizers) before and after administering medications. 3. LVN 7 failed to sanitize a glucometer (a device used to measure the amount of sugar in the blood, typically using a small drop of blood placed on a test strip) according to manufacturer's instructions before placing it back in the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide personal hygiene for one of eight sampled residents (Resident 46) when Resident 46's fingernails were long and not cut. This failure had the potential to result in Resident 46 to develop skin infections or sustain skin injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of seventeen sampled residents (Resident 32 and 236) were free from unnecessary medications when: 1. Monitoring for behaviors and non-pharmaceutical interventions were not implemented for Resident 236 while administering anti-psychotic medications (a medication used to treat a collection of symptoms that affect your ability to tell what's real and what is not). 2. Resident 32 did not have monitoring orders for her anxiety and bipolar disorder in place upon her admission to the facility on [DATE]. These failures placed Resident 32 and Resident 236 at risk for receiving unnecessary antipsychotic medications and had the potential of preventing them from maintaining their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 21) food preferences were accommodated when halal (Halal food is prepared and processed in accordance with Islamic law and dietary standards outlined in the Quran) meat was not served. This failure had the potential to place Resident 21 at risk for not meeting his nutritional status and feeling worried and anxious about his health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of eight sampled residents (Resident 60) fluid consistent with resident needs and preferences when Resident 60's standing order (a written instruction from a healthcare provider that authorizes nurses, pharmacists, or other healthcare professionals to perform specific tasks or administer treatments without the need for an individual order each time) included apple juice and Resident 60's dislikes included apple juice. This failure placed Resident 60 at risk of not having sufficient fluid intake to maintain proper hydration.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practices for one of nine sampled residents (Resident 59) when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete with section B (Medical Interventions) unmarked. This failure had the potential for Resident 59's decisions regarding treatment options and end of life wishes to not be honored.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure drugs and biologicals were stored in locked compartments and not left unlocked while they were unattended by authorized staff. This deficient practice was observed for 2 of 2 treatment carts in the facility and had the potential to affect all residents who resided on the 200 and 300 halls.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident was assessed to determine if self-administration of medication was clinically appropriate for 1 (Resident #48) of 6 sampled residents reviewed for medication administration. Specifically, Resident #48 was found with two white pills in a small cup at bedside with no staff present without an assessment of the resident's ability to safely self-administer the medication.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to ensure a Level II evaluation was completed after a positive Level I Preadmission Screening and Resident Review (PASARR) for 1 (Resident #65) of 1 sampled resident reviewed for PASARRs.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure staff monitored the skin as ordered by the physician for 1 (Resident #36) of 2 sampled residents reviewed for skin issues.

Inspectors wroteBased on observations, interviews, record review, and policy reviews, the facility failed to ensure a bi-level positive airway pressure (BiPAP) mask and an updraft nebulizer mask were stored in a bag when they were not in use for 1 (Resident #58) of 2 sampled residents reviewed for respiratory care.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure a resident's medication regimen was free from unnecessary medications for 1 (Resident #17) of 5 sampled residents reviewed for unnecessary medications. Specifically, Resident #17 had an order for lorazepam 0.5 milligrams (mg), one tablet by mouth every six hours as needed (PRN) for anxiety and agitation started on 06/15/2023 with no specified duration (stop date).