Ansted Center

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the menu was followed as posted in the facility and as printed on resident tray cards. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #15, #21, #25, #30, #37, and #54. Facility Census: 59.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety and in a manner that prevents foodborne illness to the residents. This failed practice has the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 59.

Inspectors wroteBased on observation and staff interview the facility failed to dispose of garbage and refuse properly. The facility failed to maintain a clean and sanitary environment, creating potential health and safety risks for all residents of the facility. Facility census #59.

Inspectors wroteBased on record review and staff interview the facility failed to ensure three (3) of six (6) residents received a written notification whenever their account reached within $200 of the asset level allowed for Medicaid. Resident identifiers: #55, #27, and #10. Facility census: 59.

Inspectors wroteBased on observation and staff interview the facility failed to ensure a homelike environment for the residents. There were issues with caulking around the base of the toilets, and with base moulding as well as an issue with a bug zapper in the hallway. Room identifiers: #212, #215, Facility census: 59. a) room [ROOM NUMBER]Observation revealed missing or disrepaired caulking around the base of toilets in room [ROOM NUMBER].b) room [ROOM NUMBER]The floor molding near the sink was torn and in disrepair. The surveyor reviewed and confirmed these findings with the facility Administrator at approximately 3:20 PM.Further observation during the facility walkthrough revealed that insect control devices (bug lights) in the 100 and 200 hallways contained multiple dead insects adhered to visible sticky paper, indicating a lack of routine maintenance. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing; send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; and provide the resident and the resident representative written notice which specified the duration of the bed-hold policy. This was found to be true for two (2) of four (4) residents reviewed during the long term care survey process. Resident identifiers: #64, #10. Facility census: 59.

Inspectors wroteBased upon record review and staff interviews, the facility failed to ensure the accuracy of the Pre-admission Screening and Resident Review (PASARR) of residents upon admission to the facility. This was found to be true for three (3) of seven (7) residents reviewed during the long term care survey process. Resident identifiers: #18, #8, and #64. Facility census: 59.

Inspectors wroteBased on observation, interview and policy review the facility failed to provide nail care to dependent residents to ensure nails were short, and smooth to avoid injury. Resident identifiers: #53. Facility census: 59.a) Resident #2 On 03/24/26 at 9:53 AM observation revealed Resident #2 had long, jagged unkept fingernails. The resident said she would like to have the nails shorter. On 03/24/26 at 2:00 PM Registered Nurse #4 was told what the residen [NAME] said regarding her fingernails. b) Resident #39 On 03/25/26 at 12:49 PM an observation of Resident #39 revealed this residen [NAME] long, jagged unkept fingernails. He said he would like to have them trimmed but was not sure who would do it. c) Resident #42 On 03/24/26 during the lunch meal observation revealed Resident #42 had long, jagged unkept fingernails. He said he would like to have them shorter. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medical records were accurate and complete. This was true for three (3) of five (5) residents reviewed under the care area of unnecessary medications. One relating to a Physicians Order for Scope of Treatment (POST) form, one for a vaccination witness and one for medical diagnoses. Resident Identifiers: #8, #18 and #64. Facility Census: #59.

Inspectors wroteBased on a review of Centers for Disease Control and Prevention (CDC) guidance, medical records, and staff interviews, the facility failed to follow established disease control and prevention protocols. The following issues were identified: A staff member was observed carrying linens against their clothing. A staff member failed to wear a gown while providing incontinence care to a resident on enhanced barrier precautions. Signage on a resident's door failed to identify which specific bed required enhanced barrier precautions. Resident identifier: #4. Facility census: 59. b) Resident #4 On 03/24/26 at approximately 9:45 AM, it was observed that Nurse Aide (NA) #46 was providing incontinence care to Resident #4 behind a closed divider curtain. NA #46 was subsequently seen exiting the curtained area with bagged linens and incontinence products while not wearing a gown. [...]

Inspectors wroteBased on resident interview and staff interview the facility failed to provide reasonable accommodations of needs for Resident #39. This was found true for one (1) of 29 residents reviewed. Resident identifier: #39. Facility census: 59.

Inspectors wroteBased on record review and staff interview the facility failed to ensure two (2) of two (2) residents were provided quarterly statements. Resident identifiers: #41, and #24. Facility census: 59.

Inspectors wroteBased upon record review and staff interview, the facility failed to ensure a new Pre admission Screening and Resident Review (PASARR) was completed when three (3) of seven (7) residents developed a new mental disorder. Resident identifiers: #7, #22, #53. Facility census: 59.

Inspectors wroteBased on observation, staff interview, resident interview and record review, the facility failed to ensure oxygen therapy was provided at the correct setting per the physician's order and the resident's care plan. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #37. Facility Census: 59.

Inspectors wroteBased on observation, record review and staff interview the facility failed to follow the Bed Safety Evaluation and Bed Safety Evaluation Follow-up for bed rails in order to avoid risks including entrapment due to the use of bed rails. This was true for one (1) of two (2) assessments for bed rails. Resident Identifier: #44. Facility Census: #59a) Resident #44 On 03/23/26 at 3:11 PM, Resident #44 was observed with bilateral bed rails in use. A subsequent review of the bed safety evaluation dated 01/25/26 indicated that bed rails should not be used for this resident. According to the evaluation's Step 2 guidance, if a No was recorded for any of the eight mobility questions, staff were instructed to attempt alternatives. The assessment dated [DATE] recorded No for all seven mobility questions. [...]

Inspectors wroteBased on record review, hospital staff and facility staff interviews, the facility failed to ensure Resident #63 was permitted to return to the facility following a hospitalization for behavioral evaluation. The facility's refusal to readmit the resident was based on behaviors that occurred prior to the hospitalization. Resident Identifier: #63. Facility Census: 60.a) Resident #63 Record review revealed Resident #63 was transferred to the local emergency room on [DATE] due to aggressive behavior. Progress notes from [DATE] documented the resident exhibited increased agitation and verbal aggression and was sent to the local emergency room for further evaluation per physician order. Interview with Hospital Care Manager (HCM) (#75) on [DATE] revealed the facility refused to take the resident back. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide required written notice to the resident, resident representative, and the long-term care ombudsman prior to discharging Resident #63 and refusing readmission following hospitalization. The facility's failure to issue appropriate notice deprived the resident and representative of their right to appeal and participate in discharge planning. Resident Identifier: #63 Facility Census: 60Findings included:a) Resident #63Record review showed Resident #63 was transferred to the on 09/04/25 and remained hospitalized beyond the bed-hold period. Despite hospital documentation showing the resident was ready for return, the facility declined readmission. Interview with the Hospital Care Manager confirmed the resident and representative were not notified in writing of the facility's decision to refuse the resident's return. [...]

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to ensure they served food at palatable temperatures. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the complaint survey process. Resident identifiers #2, #44, and #3. Facility census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the residents with an environment free from abuse from other residents. Resident #9 was physically abused by Resident#159. Resident #159 slapped Resident #9in the face. This was determined as Past Non-Compliance immediate jeopardy. Immediate jeopardy was determined to begin on 06/22/24 and was abated on 07/11/24. Resident identifiers: #159, #9. Facility census: 60.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents were assessed to identify risk factors and provide care and services that are resident centered to prevent falls with injury and to ensure medications were administered as ordered. This was true for 3 (three) of 6 (six) residents reviewed for the Long Term Care Survey Process. Facility census: 60. Resident identifiers:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure they implemented written policies and procedures that prohibited physical abuse, and investigated allegations of physical abuse. Resident #9 was physically abused by Resident#159. Resident #159 slapped Resident #9in the face. This was determined as Past Non-Compliance. Resident identifiers: #159, #9. Facility census: 60.

Inspectors wroteBased on record review, medical record review, staff interview and the facility abuse prohibition policy review, the facility failed to report abuse. Resident #9 was verbally abused and then physically abused. Resident identifiers: 159, #9. Facility Census: 60. Findings Included: a) On 09/30/24 at approximately 12:15 PM during a record review revealed Resident #159 had slapped Resident #9 in the face on 07/11/24 at 4:56 PM. Resident #9 was noted to have redness to the left side of face. During a review of the investigation and the staff interviews obtained at the time of the incident, the staff interview for Nurse Assistant (NA) #20's statement began with After first incident . During an interview with NA #20 at 3:15 PM on 09/30/24. NA #20 stated that Resident #159 was yelling and screaming. NA #20 said, It was the first time I saw him hit someone. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure they had evidence that allegations of abuse were thoroughly investigated. Resident #9 was physically and verbally abused by Resident#159. Resident #159 slapped Resident #9in the face. Prior to this Resident #159 threatned harm to Resident #9. The facility did not identify this verbal abuse nor did they investigate it. This was determined as Past Non-Compliance. Resident identifiers: #159, #9. Facility census: 60.

Inspectors wroteBased on record review and observation, the facility failed to ensure accuracy of assessment for one (1) of two (2) residents reviewed for dental status. Resident identifier: #37. Facility census: 60.

Inspectors wroteBased on medical record review and staff interview the facility failed to update Preadmission Screening and Resident Review (PASRR)with new qualifying diagnosis of . This was a random opportunity of discovery during the long-term care survey process. This had the ability to affect a minimum number of residents. Resident identifier: #159. Facility Census: 60. Findings Included: a) Resident #159 During a medical record review on 09/30/24 at approximately 10:30 AM it was identified that Resident #159 admitted on [DATE]. It is further identified that the resident did not have capacity with a Brief Interview for Mental Status (BIMS) of six (6) and was admitted with the following diagnoses dated 02/10/24: [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to update Preadmission Screening and Resident Review (PASRR) after one resident's behaviors intensified. This was a random opportunity of discovery during a long-term care survey process. This had the ability to affect a minimum number of residents. Resident Identifier: Resident #159. Facility Census: 60. Findings Included: a) Resident #159 During a medical record review on 09/30/24 at approximately 10:30 AM it is identified that Resident #159 was admitted on [DATE]. It is further identified that the resident did not have capacity with a Brief Interview for Mental Status (BIMS) of six (6) and was admitted with the diagnosis; During a review of the PASSR completed prior to the resident's admission, the PASSR was completed accurately and did not require Level II. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents were assessed to identify risk factors and provide care and services that are resident centered to prevent falls with injury by failing to develop and implement a resident centered fall risk care plan. This was true for 1 (one) of 6 (six) residents reviewed. Resident identifier: #162. Facility census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to provide resident centered activities. A resident was not provided individual activities. This is idenified as Past Non Compliance. Resident identifiers: #159, #9. Facility Census: 60. Findings Included: a) Resident #159 On 09/30/24 at approximately 12:15 PM during a record review of a an incident it was identified that Resident #159 had slapped Resident #9 in the face at 07/11/24 at 4:56 PM and Resident #9 face was noted to have redness to the left side. During a review of the investigation the Nurse Assistant (NA) #20's statement began with After first incident . During an interview with NA #20 at 3:15 PM on 09/30/24 NA #20 stated that on 07/11/24 Resident #159 was yelling and screaming but it was the first time she saw him hit someone. [...]

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure fall interventions were in place for Resident #27 and to ensure a mechanical lift was used, per company policy, to assist Resident #159 out of the floor following a fall. This was true for two (2) of five (5) residents reviewed for accidents during the survey process. Resident identifiers: #27, 159. Facility census: 60.

Inspectors wroteBased on record review and resident and staff interview, the facility Medical Director (MD) failed to sign orders in a timely manner to ensure Resident #37 did not miss doses of a controlled pain medication. This was true for one (1) of three (3) residents reviewed for pain management during the survey process. Resident identifier: 37. Facility census: 60.

Inspectors wroteBased on observation and staff interview the facility failed to to ensure two (2) residents was supplied with working call light. and/or accessible call lights. Resident #2's call light was not working and#55's call light was not within reach. Facility census: 60.

Inspectors wroteBased on observation, policy review, family interview, staff interview and medical record review the facility failed to ensure a resident who received nutrition through a Gastrostomy tube (G-tube) received sufficient caloric intake daily to prevent weight loss. Harm occurred when the resident experienced a significant weight loss and G-tube feedings were held. The G-tube feedings were held to encourage the resident to eat by mouth, but the facility failed to have a plan in place to ensure caloric intake would be maintained if the resident did not eat by mouth. This was true for one (1) of three (3) residents reviewed who receive nutrition via a G-tube. Resident #55. Facility Census: 57.

Inspectors wroteBased on observation and staff interview the facility failed to keep the kitchen equipment in sanitary conditions. The ice machine in the kitchen contained black substance in the ice bin. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility census: 57 Findings Included: a) The improper sanitization of the Ice Machine During the initial tour of the kitchen on 07/10/23 The Food Service Director (FSD) was not present upon entering the facility. [NAME] #63 was in charge of the building. During an observation of the Ice Machine in the kitchen, it contained a black substance inside the ice bin. [NAME] #63 stated the Maintenance department was in charge of cleaning the cleaning machine monthly. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and complete record for . This was true for five (5) residents reviewed. Resident identifiers: #12, #52, #3, #23, #55. Facility Census: 57.

Inspectors wroteBased on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The ice machine in the kitchen did not have a one inch air gap for drainage. This failed practice had the potential to affect all residents currently receiving nutrition from the facility kitchen. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to ensure one (1) resident had the right to participate in the development of their care plan. Resident identifier: #52. Facility census: 57.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The walls in Resident #52's room were not in good repair. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents that currently reside in the facility. Resident Identifier: #52. Facility Census: 57. Findings Included: a) Resident #52 During the initial tour, on 07/10/23 at 10:47 AM, an observation of Resident #52's room walls revealed several screw holes, and several places with missing paint around the television area. There were also several scuff marks and missing paint on the walls near the floor and near the bathroom door. There was a doorknob-size hole in the wall behind the room door. [...]

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure a resident had a person-centered comprehensive care plan developed and implemented to meet his/her other preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of (16) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the resident at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #42. Facility census: 56.

Inspectors wroteBased on medical record review, resident interview and staff interview the facility failed to ensure they revised a care plan after fall occurred. This was true for one (1) out of 15 reviewed for care plans. Resident identifier: #1. Facility Census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure medications were dated upon opening and disposed of when expired in accordance with accepted standards of care. This was a random opportunity for discovery. Facility Census: 57.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure all handrails were securely affixed to the walls. This was a random opportunity for discovery and the potential to affect more than a limited number of residents who currently reside in the facility. Facility census 57.