Anchor Lodge Nursing Home Inc

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure residents received a preadmission screening and resident review (PASRR) when the resident had diagnoses of a serious mental illness (SMI), and was prescribed psychotropic medication. This affected one (Resident #6) of two residents reviewed for preadmission screening and resident review. The facility census was 91. Findings Included:Review of the medical record revealed Resident #6 admitted to the facility on [DATE]. Diagnosis included bipolar disorder, major depressive disorder, and anxiety disorder. Review of Resident #6's Preadmission Screening and Resident Review (PASRR) dated 01/13/2022, indicated the resident had diagnoses of panic or other severe anxiety disorder, bipolar disorder, and depression and had not been prescribed any psychotropic medications within the last six months. [...]

Inspectors wroteBased on medical record review, observation, interview, and policy review, the facility failed to ensure the medication error rate was less than 5 percent. There were 31 observed medication opportunities with three medication errors, resulting in a calculated medication error rate of 9.68 percent. This affected two (Resident #32 and Resident #11) of six residents observed for medication administration. The facility census was 91. Findings Included:1. Review of the medical record revealed Resident #32 admitted to the facility on [DATE]. Diagnoses included asthma, major depressive disorder, and epilepsy. [...]

Inspectors wroteBased on medical record review, observation, interview, and policy review, the facility failed to ensure the accuracy of the medical record. This affected one (Resident #32) of six residents observed for medication administration. The facility census was 91. Findings Included:Review of the medical record revealed Resident #32 admitted to the facility on [DATE]. Diagnoses included asthma, major depressive disorder, dysphagia (difficulty swallowing) following a cerebral infarction (stroke), gastrostomy status (a surgical opening into the stomach to place a feeding tube), and epilepsy. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2025, revealed Resident #32 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. [...]

Inspectors wroteBased on medical record review, observation, interview, and policy review, the facility failed to ensure staff wore proper personal protective equipment (PPE) when providing care. This affected one (Resident #32) of one resident reviewed for feeding tubes, who was on enhanced barrier precautions (EBP). The facility census was 91. Findings Included:Review of the medical record revealed Resident #32 was admitted on [DATE]. Diagnoses included oropharyngeal dysphagia (difficulty swallowing) following a cerebral infarction (stroke) and gastrostomy status (a surgical opening into the stomach to place a feeding tube). Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2025, revealed Resident #32 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. [...]

Inspectors wroteBased on observations, medical record review, review of the incident log, review of facility in-services records, review of a personnel file, review of the safety inspection bus checklist, review of witness statements and the facility ' s internal investigation, review of policies, review of the emergency medical transportation report, review of hospital records, review of the monthly maintenance logs, interview with the medical director, and resident and staff interviews, the facility failed to ensure a resident dependent on staff, was safely secured in the wheelchair with a seat belt during transportation in a facility bus when coming back from a physician visit. [...]

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, resident council minutes review, and review of policy, the facility failed to ensure food was palatable related to temperature and taste. This had the potential to affect 86 of 86 residents residing in the facility. The facility census was 86.

Inspectors wroteBased on medical record review, hospital record review, staff interview, hospital staff interview and policy review, the facility failed to ensure a written discharge notice with the provisions of the discharge was provided to a resident who went to the hospital. This affected one (#37) out of three residents reviewed for transfer, discharge from the facility. The facility census was 86.

Inspectors wroteBased on medical record review, hospital record review, staff interview, hospital staff interview and policy review, the facility failed to ensure a resident who went to the hospital and was not provided a discharge from the facility, was allowed to return to the facility. This affected one (#37) of three residents reviewed for transfer, discharge from the facility. The facility census was 86.

Inspectors wroteBased on observation, family interview, staff interview, hospice interview, medical record review and review of policy, the facility failed to ensure a resident, who was dependent on staff for incontinence care, was not being dressed in multiple incontinence products at one time, when staff place multiple incontinence liners inside the incontinence brief. This affected one (#27) of three residents reviewed for incontinence care. The facility census was 86.

Inspectors wroteBased on record review, staff interview and review of the policy, the facility failed to ensure a resident with post-traumatic stress disorder was provided scheduled psychotropic medication to maintain stable mental health. This affected one (#37) of four residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on medical record review, staff interview, hospice interview and review of the policy, the facility failed to ensure psychotropic medication administration was accurately documented and failed to ensure non-pharmacological interventions were attempted prior to administration of an antianxiety medication. This affected one resident (#27) of three residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure weights were obtained per physician order, and ongoing monitoring was provided for residents identified at nutritional risk and sustaining weight loss. This resulted in Actual Harm when Resident #66 experienced a severe weight loss of 10.8 % from 07/26/22 to 10/17/22. There was no evidence weekly weights were obtained per physician order or that subsequent monitoring or interventions were considered or implemented during this time. Additionally, the facility failed to ensure Resident #51's weekly weights were obtained per physician orders, which placed the resident at risk for more than minimal harm that did not result in actual harm to the resident. This affected two (#66 and #51) of three residents reviewed for nutrition. The facility census was 82.

Inspectors wroteBased on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure residents were served meals in a dignified manner. This affected seven (#7, #10, #11, #21, #33, #64, and #66) of 82 residents observed for dining. The facility census was 82.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure proper serving for the mechanical soft meat was served. This affected two residents (#22 and #56) but had the potential to affect all 19 residents (#1, #7, #11, #16, #22, #29, #35, #42, #43, #51, #56, #57, #59, #65, #67, #71, #73, #74, and #358) that received the mechanical soft diet. The facility census was 82.

Inspectors wroteBased on observations, medical record review, resident and staff interviews, the facility failed to provide the resident the choice of when to receive a shower. This affected one (#77) of three residents sampled for choices. The facility census was 82.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected two (#17 and #55) of five residents reviewed for advanced directives. The facility census was 82.

Inspectors wroteBased on medical record review, staff interview, and review of the policy, the facility failed to notify the physician when a resident sustained a severe weight loss. This affected one (#66) of three residents reviewed for notification. The facility census was 82.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure the environment was maintained in a safe and clean manner. This affected five (#10, #45, #71, #74 and #76) of 82 resident's environment observed. The facility census was 82.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents and/or their representatives received written transfer notices when transferred to the hospital. This affected two (#81 and #36) of two residents reviewed for hospitalizations. The facility census was 82.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents and/or their representatives received the bed hold notices in writing when transferred to the hospital. This affected two (#81 and #36) of two residents reviewed for hospitalizations. The facility census was 82.

Inspectors wroteBased on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure a dependent resident was provided assistance with grooming. This affected one (#61) of four reviewed for activities of daily living (ADL). The facility census was 82.

Inspectors wroteBased on medical record review and staff interview, the facility failed to monitor and treat residents who had limited bowel movements. This affected two (#10 and #79) of five reviewed for bowel and bladder. The facility census was 82. Findings Include: 1. Review of medical record for Resident #10 revealed an admission date of 12/28/21. Diagnoses included Parkinson's Disease, unspecified dementia, bipolar disorder, and anxiety disorder. Review of the plan of care dated 01/10/22 revealed the resident had the potential for alteration in bowel elimination. Interventions included to assist with toileting as needed, record all stools, and report irregularities to the charge nurse. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/04/22, revealed the resident had intact cognition. The resident required extensive assistance for toileting. [...]

Inspectors wroteBased on observations, medical record review, review of policy, and staff interview, the facility failed to ensure measures were in place to change and date oxygen tubing and saline bottles for use with oxygen concentrators. This affected one (#337) of one resident reviewed for respiratory care. The facility census was 82.

Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to ensure medical transportation was set up for a resident to attend a physician appointments. This affected one (#77) of two residents reviewed for transportation. The facility census was 82.

Inspectors wroteBased on medical record review, laboratory review and staff interview, the facility failed to ensure a pharmacy recommendation for laboratory test to monitor medications was completed. This affected one (#18) of five residents reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on medical record review, observations, Humalog Kwickpen procedure review and staff interview the facility failed to ensure a resident was free from significant medication error as evident by not priming the insulin pen-injector before administration. This affected one (#70) of eight residents observed for medication administration. The facility census was 82.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure meals provided to a resident accommodated the resident's allergies and preferences. This affected one (#66) of three residents reviewed for nutrition. The facility census was 82.

Inspectors wroteBased on record review, observations and staff interview, the facility failed to administer medications in a sanitary manner. This affected two (#34 and #59) of eight residents observed for medication administration. The facility census was 82.

Inspectors wroteBased on observations, medical record review, review of facility advanced directives policies and staff interviews, the facility failed to accurately identify code status the residents. This affected two (#72 and #89) of 27 residents reviewed for advance directives. The facility census was 92.

Inspectors wroteBased on medical record review, observation, resident and staff interview and review of facility policy, the facility failed to ensure residents who required staff assistance with activities of daily living (ADL) received adequate care. This affected one (Resident #86) of three residents reviewed for ADLs. The facility census was 92. Findings Include: Medical record review of Resident #86 revealed an admission date of 05/17/19. Diagnoses included hypertension, anemia, and acute embolism and thrombosis of unspecified deep veins of lower extremity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/04/19, revealed the resident had intact cognition. The resident was extensive assistance of one for dressing and personal hygiene. [...]

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to implement pressure relieving devices in a timely manner for a resident identified to have new skin breakdown. This affected one (Resident #299) of four residents reviewed for pressure ulcers. The facility identified nine residents who had pressure ulcers. The facility census was 92.

Inspectors wroteBased on medical record review, review of the facility and dialysis transfer agreement and staff interview, the facility failed to ensure ongoing communications occurred between the facility and the dialysis provider. This affected one (Resident #51) of one resident reviewed for dialysis. The facility identified three residents receiving dialysis services. The facility census was 92.

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to serve meal trays in a sanitary manor. This had the potential to affect Resident #57 who received a lunch hall tray on the 100 hall. The facility census was 92.

Inspectors wroteBased on observation, review of posted staffing information and staff interview, the facility failed to ensure posted staffing information contained all required elements and posted prominently in the facility. This had the potential to affect all 92 residents residing in the facility. Findings Include: Observation during the annual survey of the facility on 10/28/19 to 10/30/19 at 8:34 A.M., revealed staffing information was not posted prominently for residents and visitors to review. The posted daily staffing information was located at the receptionist area laying on the counter and was absent of the facility's daily resident census. Interview on 10/30/19 at 8:34 A.M., with License Practical Nurse (LPN) #200 and #204 revealed there were no daily staffing information posted in view and did not know where they were posted. Interview on 10/30/19 at 9:06 A.M. [...]