Anchor Care & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide a system for preventing and controlling infections and communicable diseases for residents by not offering hand hygiene to residents who ate in the dining rooms. This affected approximately 25 residents in the main dining room at lunch and 10 at dinner meals and approximately 10 residents in the small restorative dining room at the lunch meal each day. Findings: On 6/09/25 at 11:12 AM, 20 residents were located in the main dining room in preparation for lunch. Staff was observed as they put napkins on the tables for residents, but no hand hygiene was offered to residents before the meal. On 6/10/25 at 10:53 AM, 20 residents were again seated in the main dining room in preparation for lunch. Staff was seen placing linen tablecloths on the tables. At 11:07 AM, one staff member passed out napkins while another began the meal service by serving soup and another staff served beverages. By 11:13 AM, 25 residents total in the dining room had no hand hygiene offered prior to the meal. On 6/11/25 at 3:55 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 45 residents, (#62). Findings: Resident #62 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, essential hypertension, anemia, major depressive disorder, anxiety disorder, and sepsis. Review of the Minimum Data Set quarterly assessment with assessment reference date of 5/02/25 revealed resident # 62 was cognitively intact. A review of resident #62's medical record revealed no physician's orders for eyedrops, no assessments for self-administration of medications nor did it contain a care plan which reflected self-administration and storage arrangements. On 6/11/25 at 9:40 AM, resident # 62 was observed in her room seated in a wheelchair with a bedside table in front of her. On the bedside table…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices for two of two residents reviewed for call bells, of a total sample of 45 residents, (#80 and #259). Findings: 1. Resident #80 was admitted to the facility on [DATE] for hypertension, depression, insomnia, emphysema, and a urinary tract infection. According to the discharge Minimum Data Set (MDS) dated [DATE] for a short-term hospital stay, it indicated the resident was able to make his own decisions regarding tasks of daily life and was able to communicate in a logical and coherent manner. Resident #80's care plan indicated he was at high risk for falls, and his use of his call light was to be encouraged for standing, transferring and ambulation. There was a care plan which included resident was at risk for skin breakdown due to incontinence with an intervention to check for incontinence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the kitchen freezer (essential equipment), in safe operating condition. This had the potential to affect all 106 residents who ate meals at the facility. Findings: On 6/09/25 at 10:00 AM, during the kitchen tour with the Dietary Manager, it was noted in the walk-in freezer that ice [NAME] had built up on the evaporator and water was dripping onto the boxes stored below it. The Dietary Manager relocated approximately six boxes of food whose tops were covered in ice from the leak to a different shelf. She confirmed she needed to get with the maintenance department to have them come check out and repair the freezer. On 6/10/25 at 11:30 AM, the Director of Maintenance and Regional Manager of Maintenance stated they were not previously aware there was ice buildup and a leak from the evaporator in the freezer. They confirmed none of the kitchen staff had informed them of the issue, but said they would check it out. On 6/10/25 at 4:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility's oxygen concentrator external filters were clean and in safe operating condition for 3 of 6 residents reviewed for respiratory care out of a total sample of 51 residents, (#37, #84, #197). Findings: Review of resident #37's medical record documented he was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Acute and Chronic Respiratory Failure Review of the physician's orders revealed oxygen at 4 liters (L) per minute via nasal cannula. Review of the 5 day Minimum Data Set (MDS) assessment dated [DATE] documented resident received oxygen therapy. Review of resident #37's plan of care for at risk for cardiovascular complications dated 07/20/20 with intervention to administer oxygen as ordered. Observations conducted on 03/07/22 at 2:43 PM, 03/08/22 at 10:37 AM and on 03/09/22 at 10:21 AM revealed the oxygen concentrator's external filter was covered with gray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide showers as per resident's preferences and as per shower schedule for 2 of 8 residents reviewed for choices, out of a total sample of 51 residents, (#84 #34). Findings: 1. Review of resident #84's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident (CVA), Epilepsy, Diabetes Mellitus, Metabolic Encephalopathy, Acute Respiratory Failure and Morbid Obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, required extensive assistance with Activities of Daily Living (ADL) and total assistance with bathing. Review of the plan of care documented resident #84 was at risk for decreased ability to perform ADL's with bathing, grooming, personal hygiene and transfers related to CVA and interventions to transfer resident using mechanical lift with 2 staff members. On 03/07/22 at 1:46 PM, resident #84 stated, I would like to have a shower but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure prompt investigation and timely resolution of concerns for 1 of 1 resident reviewed for grievances, out of a total sample of 51 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included stroke, type 2 diabetes, speech and language deficit, muscle weakness and adult failure to thrive. On 3/10/22 at 11:15 AM, resident #1 stated during her stay in the facility, a suitcase which contained her birth certificate, passport and resident alien identification card had been lost when she was moved to another room. She explained the facility replaced the suitcase in December 2021, over a year after it was lost. She stated none of the contents of the suitcase were replaced. Resident #1 stated facility staff made several excuses. She said, They say they are waiting for corporate and waiting for the State. I don't know who corporate is. The resident stated she completed a grievance form in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete Minimum Data Set (MDS) Assessments within the required timeframe for 2 of 8 residents reviewed for MDS Assessments, of a total sample of 51 residents (#52 and #78). Findings: 1. Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include quadriplegia, pressure ulcer on right and left buttocks. On 2/17/22 the resident was transferred from the facility to the hospital and returned to the facility on 2/21/22. Review of the MDS Discharge Return Anticipated assessment dated [DATE] and Entry assessment dated [DATE], revealed both assessments were marked still in progress. On 3/11/22 at 1:33 PM, MDS Coordinator D stated the MDS assessments should be completed within 14 days. She confirmed the Discharge Return Anticipated dated 2/17/22 should have been completed by 3/03/22 and the Entry assessment dated [DATE] should have been completed by 3/07/22. She said she had other job duties and did not always have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessments accurately reflected health conditions for 2 of 6 residents of a total sample of 51 residents, (#69, #55). Findings: Resident #69 was admitted to the facility on [DATE] with diagnoses that included cerebral atherosclerosis and dementia. The physician orders revealed an order to admit to Hospice dated 10/15/21. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] section O-Special Treatments, Procedures, and Programs reflected the Hospice section response was NO. Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of heart disease, and hypertension. Review of the physician orders revealed an order for diuretic medication, Chlorthalidone daily to treat blood pressure and fluid retention. Review of the Medication Administration Record (MAR) revealed the resident received Chlorthalidone daily since 4/07/21. Review of the 5-day MDS assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician order for a positioning device recommended by Occupational Therapy, and failed to provide care and services for appropriate placement of the device, to prevent further decrease in range of motion for 1 of 1 resident reviewed for positioning and mobility out of a total sample of 51 residents, (#53). Findings: Resident #53 was admitted from the hospital on 8/15/19 with diagnoses including dementia, stroke with right side paralysis and weakness, muscle weakness, abnormal posture, and pain and stiffness in her right shoulder, elbow, and hand. Review of the Minimum Data Set Medicare End of Part A Stay assessment, with assessment reference date of 1/15/22 revealed resident #53 was totally dependent on two persons for assistance with activities of daily living. Section O of the MDS assessment showed the resident received neither Restorative Nursing Program (RNP) nor active and passive range of motion care and services. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing was changed as per professional standards of practice for 1 of 1 resident reviewed for infection of a total sample of 51 residents, (#149). Findings: Resident #149 was admitted to the facility on [DATE] with diagnoses of osteomyelitis of vertebra, lumbar region, sepsis, hemoptysis, chronic pain syndrome, acute and subacute endocarditis, Methicillin Resistant Staphylococcus Aureus (MRSA), and chronic hepatitis. Physician's order dated 2/25/22 read, change PICC line dressing q (every) week and PRN (as needed). A PICC line is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart .It is used to give intravenous fluids, blood transfusion .and other drugs. (retrieved from www.cancer.gov Definition of PICC 3/21/22) On 3/07/22 at 4:36 PM, and on 3/08/22 at 4:20 PM, observations showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Oxygen (O2) therapy was administered as per physician's order for 1 of 5 residents reviewed for O2 therapy of a total sample of 51 residents, (#143). Findings: Resident #143 was admitted on [DATE] with diagnoses of encephalopathy, sepsis, atherosclerotic heart disease, dementia without behavioral disturbance, acidosis, and anemia. Physician's order on 3/02/22 read, Oxygen at 3 liters/minute (L/M) via nasal cannula (NC) as needed for shortness of breath/for saturations below 92%. On 3/07/22 at 12:07 PM, and 2:39 PM, and on 3/08/22 at 11:37 AM, showed resident #143 lying in bed with his eyes closed. The oxygen concentrator was infusing at 2 L/M. On 3/08/22 at 11:41 AM, Licensed Practical Nurse (LPN) K stated the resident was on oxygen at 2 L/M. The resident's physician's order was reviewed with LPN K and she verbalized the order was for oxygen at 3 L/M. The resident's O2 settings were observed with LPN K and she acknowledged the O2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were administered within professional guidelines/parameters for 1 of 5 residents reviewed for unnecessary medication (#145) and failed to ensure intravenous antibiotics were administered as per physician order for 2 residents, (#149, #193) of a total sample of 51 residents. Findings: 1. Review of resident #193's medical record documented he was admitted to the facility on [DATE] with diagnoses including Pneumonia, Arteriosclerotic Heart Disease (ASHD), Esophageal Perforation, with Intraabdominal infection, Elevated [NAME] Blood Cell Count and Abscess of the Stomach. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 03/03/22 documented the resident ambulated independently, was able to transfer self and was partial weight-bearing. Review of resident #193's plan of care dated 03/07/22 for resident has an active PNA (Pneumonia) infection with intervention to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain dental services for 1 of 2 residents reviewed for dental services out of a total sample of 51 residents, (#84). Findings: Review of resident #84's medical record documented she was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Epilepsy, Seizures, Cerebral Vascular Accident (CVA) and Acute Respiratory Failure. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented she had no cognitive issues, was on a mechanically altered/therapeutic diet and had obvious or likely cavity or broken teeth. Review of resident #84's plan of care noted resident had a dental or oral problem related to broken teeth dated 02/28/22. The goal included the resident to be free of infection, pain or bleeding in the oral cavity through review date of 06/03/22. The intervention included dental referral as needed. On 03/07/22 at 1:32 PM, resident #84 stated she had been missing her front bottom teeth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.