Anchor Post Acute

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the kitchen's floor and equipment including two ovens, the shelves on two metal rolling carts, three stove top spill pans, three metal racks, one reach in freezer, five food preparation pans, and large manual can opener and its base attachment were kept clean. These failures had the potential to create an environment for food-borne illnesses which could affect 102 residents who consumed food prepared from the facility's kitchen. Review of the facility's policy titled, Sanitation revised on 04/2006 indicated, Policy Statement-The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchen, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish . 2. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one of 24 (Residents (R)1) reviewed for comprehensive care plans failed to include the care required for R1's nephrostomy tube. care plan directing measurable goals and interventions for one of a total sample of 29 residents. This failure placed the resident at risk for unmet care needs, and the inability to meet their maximum practicable level of functioning. Review of the facility's policy titled, Care Planning - Interdisciplinary Team dated March 2022 included, .the Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (lDT). [...]

Inspectors wroteBased on review of facility policy, record review, observations and interviews, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL) assistance received services for one of four residents (Resident (R) R63) reviewed for fingernail care and bathing in a total sample of 24 residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issueReview of the facility's policy titled Fingernails/Toenails, Care of dated 2002 documented, .Nail care includes daily cleaning and regular cleaning. Proper nail care can aid in the prevention of skin problems around the nail bed. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure two of three residents (Resident (R)15 and R63) reviewed for respiratory care in a sample of 24 residents received oxygen as ordered by the physician and R15s oxygen unit was clean and sanitary. This failed practice has the potential to cause respiratory issues and /or infections for residents. Review of the facility's policy titled Oxygen Administration dated October 2001 documented, .Verify that there is a physician's order for this procedure. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to have medications available for administration for one (Resident (R) 57) of seven sampled residents whose drug regime was reviewed in a total sample of 24 residents. The facility failed to have R57's Clonazepam medication (Generic name- Klonopin which is an antianxiety medicine) available to administer as prescribed for two days, which caused the resident to not feel well and have increased anxiety. Review of R57's admission Record revealed R57 was admitted to the facility on [DATE] and had diagnoses of which included bipolar disorder, anxiety disorder, and major depressive disorder. [...]

Inspectors wroteBased on interview, test tray observation, record review, and facility policy review, the facility failed to serve food that was palatable and hot to four of four residents (Resident (R) 4, R35, R57, and R80) reviewed for food palatability out of a total sample of 24 residents. This failure had the potential to affect 102 residents who consumed food prepared from the facility's kitchen and could result in residents skipping meals and experiencing weight loss. Review of the facility's policy titled Food and Nutrition Services dated 10/17 indicated, Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . 7. [...]

Inspectors wroteBased on observations, record review, interview, and review of Centers for Disease Control (CDC) guidelines, the facility nursing staff failed to wear Personal Protective Equipment (PPE) when providing direct care for one of one (Resident (R)1) reviewed for Enhanced Barrier Precautions (EBP) in the sample of 24 residents. This could place this resident and other residents and staff at risk of infection by cross-contamination. Observation on 09/09/25 at 10:30 AM of R1 lying in bed revealed a small black bag hanging on the side of her bed. Interview with Certified Nursing Assistant (CNA)3 at this time confirmed that R1 has a nephrostomy tube. [...]

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to ensure safe and secure storage of medications and biologicals in 2 of 2 medications observed.

Inspectors wroteBased on observations, interviews, document review, and facility policy review, the facility failed to ensure the ice machine remained clean and not contaminated, ensure proper hand hygiene when serving food from the steam table, ensure proper handwashing when going from a dirty to a clean area, and ensure staff (Cook1) wore a beard guard for one of one kitchen. These failures had the potential to affect 105 residents in the facility who consumed food from the kitchen.

Inspectors wroteBased on interviews, observations, record review, and facility policy review, the facility failed to serve food that was palatable as expressed by five of five residents (Resident (R) 26, R27, R52, R53, and R55) in a group interview, in that the hot foods when served to the residents did not taste hot and the food was not seasoned. This had the potential to affect 105 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide resident care in a manner that prevented cross-contamination for one of one resident (Resident (R) 42) reviewed for catheter care of 23 sampled residents. In addition, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for three of three residents (R65, R36, and R12) when providing care to residents on enhanced barrier precautions (EBP). This failure could promote the spread of multi drug resistant organisms throughout the facility.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to assess a resident for self-administration of medication for one of one resident (Resident (R) 27) reviewed for self-administration of medication of 23 sample residents. This had the potential to affect resident medication safety at the facility.

Inspectors wroteBased on interviews, document review, and review of facility policy, the facility failed to respond to resident grievances in a timely manner for one of one resident (Resident (R) 75) reviewed for grievances out of 23 sampled residents. This had the potential to affect resolution of resident concerns.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to ensure one of three residents (Resident (R) 254) reviewed for abuse were free from abuse of 23 sample residents. Specifically, R254 reported that she was afraid to push her call light due to two instances of intimidation and verbal abuse by Certified Nursing Assistant (CNA)1. This had the potential to affect resident safety at the facility.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to report staff to resident abuse when they failed to report the allegation of abuse to the State Survey Agency (SSA) for one of two residents (Resident (R) 254) reviewed for abuse of 23 sample residents. These failures had the potential to contribute to further verbal abuse and possible psychosocial harm. Findings Include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation, revised September 2022, indicated All reports of resident abuse, neglect exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (As required by current regulations) and thoroughly investigated by facility management. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a thorough investigation was conducted for an allegation of abuse for one of two residents (Resident (R) 254) reviewed for abuse of 23 sample residents. These failures had the potential to contribute to further abuse and possible psychosocial harm.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure three of three residents and/or their representatives (Resident (R) 11, R25 and R101) reviewed for facility initiated emergent hospital transfer, from a total sample of 23 residents, were provided with written transfer/discharge notice that contained the required information. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to prevent accidents for one of one resident (Resident (R) 32) when they failed to implement an intervention listed on the care plan of 23 sample residents. This failure had the potential to cause the resident harm from a fall out of bed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 6) had a gradual dose reduction (GDR) conducted according to the physician approved recommendation from the pharmacist in a timely manner of 23 sample residents. This had the potential for the resident to receive unnecessary antipsychotic medications.

Inspectors wroteBased on review of the facility's policy, record review, and staff interviews, the facility failed to ensure the completion of quarterly Minimum Data Set (MDS) assessments for three residents (Resident (R) 7, R32, and R9) of six residents reviewed for timely assessment completion.