Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anberry Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Incomplete controlled substance receiving records were found for several residents with pain management or hormone replacement orders. The CSR/CDR entries lacked required details such as received dates, times, quantities, and nurse signatures, and an LPN and the DON confirmed the records were not properly completed when meds arrived from the pharmacy.
Food storage and sanitation practices were not followed in the kitchen. A dirty pot was stored in a clean prep area, an opened veggie patty bag lacked dating, freezer fan ice buildup was present, a container of cut fruit was unlabeled and undated, open boxes of mushrooms and celery were left uncovered, food debris and liquid were on the refrigerator floor, and the countertop sanitizer bottle tested at zero instead of the expected ppm range.
Kitchen equipment was not maintained with required air gaps when the food prep sink was piped directly into the wall and the only ice machine in the facility had a drain hose positioned below the floor level. The DM, MD, and RD all acknowledged the missing air gaps, and the facility policy required air gaps for drains in areas such as ice machines and sinks.
Incomplete Behavior Monitoring for Psychotropic Medication: A resident with schizoaffective disorder, EPS, and CKD was receiving haloperidol 7.5 mg BID, but staff did not have behavior monitoring in place for the psychotropic medication. Interviews noted the resident sometimes refused care and yelled at staff, and the LVN, MDSC, and DON stated monitoring should have been started when the medication was ordered. The facility policy required adequate monitoring and documentation of behavioral interventions.
Missing Dementia Care Plan: A resident with dementia, schizoaffective disorder, and bipolar disorder did not have a care plan for dementia. An LVN and the MDSC both confirmed no dementia-focused care plan was in the record, despite the diagnosis being present since admission. The DON stated care plans should be individualized and that licensed nurses and the MDSC were responsible for ensuring care plans were developed and in place.
A resident with schizoaffective disorder, bipolar type, and anxiety disorder had clozapine orders that did not match: the order summary showed a total dose of 150 mg even though the resident was prescribed 175 mg. RN 2 confirmed the mismatch, RN 1 said it could confuse a nurse unfamiliar with the order, and the DON stated dosage information in the medication orders should match.
Failure to provide nail care and ADL assistance: Two residents had long, jagged fingernails with debris under the nails, and both stated they did not remember the last time their nails were trimmed. One resident had Alzheimer’s disease/dementia, and the other had hemiplegia, hemiparesis, and DM. Staff stated nail care was scheduled on shower days and every Sunday, CNAs were expected to assist with nail care, and the facility policy required regular cleaning and trimming of nails and documentation when care was refused.
A resident with dementia was inappropriately prescribed Quetiapine, an antipsychotic medication with a black box warning for increased mortality in elderly patients with dementia-related psychosis. The medication was prescribed for behaviors such as restlessness and sadness, despite not being approved for dementia-related psychosis. Facility staff acknowledged the inappropriate use, and the resident's physician discontinued the medication after assessment.
A resident with a history of elopement risk managed to remove the lock from a sliding door in their room and left the facility unsupervised. The facility's policies on maintenance and elopement prevention were not adequately followed, leading to the resident's unauthorized departure and subsequent emergency room visit. Staff interviews revealed that the sliding doors were supposed to be locked at all times, but the locks were simple to remove and not regularly checked.
A resident with a history of mental health issues and substance abuse eloped from their room through a sliding door that was not securely locked, despite facility policies requiring such security. Staff interviews revealed that the locks were simple to remove and not documented in maintenance checks, leading to the resident's unsupervised departure and subsequent emergency room visit.
A facility failed to ensure proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. An LVN did not perform hand hygiene after cleaning the wound and before applying medication and a clean dressing, nor did she change gloves between cleaning a second wound and applying medicated cream. Interviews with staff confirmed the LVN's actions did not align with the facility's hand hygiene policy, potentially risking infection transmission.
Incomplete Controlled Substance Receiving Records
Penalty
Summary
Pharmaceutical services were not provided to ensure accurate acquiring, receiving, dispensing, and administering of controlled medications for five sampled residents. During record review and interviews, the Controlled Substance Record (CSR) and Controlled Drug Record (CDR) for Residents 7, 8, 52, 63, and 92 were found incomplete when medications were received from the pharmacy. The missing information included received dates, received times, nurse signatures, total amounts received, medication amounts on the sheet, and, for one resident, the starting quantity and number of cc remaining. Resident 7 had orders for HYDROcodone-Acetaminophen for chronic pain, and the CDR reviewed for that resident did not indicate the total amount received, the medication amount on the sheet, the received-by signature, or the received date. Resident 8 had an order for Morphine Sulfate oral solution as needed for severe pain, and the CSR did not indicate the received date, received time, or nurse signature. Resident 52 had an order for traMADol HCL for pain, and the CDR did not indicate the total amount received, the medication amount on the sheet, the received-by signature, or the received date. Resident 63 had orders for Morphine Sulfate oral solution and traMADol HCL for chronic pain, and both the CSR and CDR were incomplete, with missing received date, received time, nurse signature, total amount received, medication amount on the sheet, and received-by signature. Resident 92 had an order for Testosterone Cyplonate solution for hormone replacement therapy, and the CSR did not indicate the start quantity, number of cc remaining, received date, received time, or nurse signature. The DON confirmed the records were not filled out and stated the facility's process required the receiving nurse to document and sign the controlled substance records when medications were received from pharmacy.
Food Storage and Sanitizing Deficiencies
Penalty
Summary
Food was stored and prepared in ways that did not follow professional food service standards in the kitchen and storage areas. During observation, a pot with white and brown debris was stored upright in a clean food prep area where clean pots were kept. The Certified Dietary Manager stated the pot appeared to have grease and food debris in it and should have been clean and stored inverted to prevent contamination. The Registered Dietician also stated the pot appeared dirty and should have been stored face down. In the walk-in freezer, a black bean veggie patty was found in an open plastic bag without an open date or use-by date. The Certified Dietary Manager stated the bag should have been dated when opened so food could be rotated properly and used within the appropriate time. The Registered Dietician stated the opened bag needed an opened and used-by date to prevent cross-contamination and food-borne illness. In the same freezer, the fan had ice buildup, and the Certified Dietary Manager stated the buildup could affect the unit’s function and could get on food. The facility’s refrigerator and freezer policy required food to be dated and freezer fan conditions to be inspected. In the walk-in refrigerator, a plastic container with sliced pink fruit was unlabeled and undated, and two open boxes containing mushrooms and celery were left uncovered. The Certified Dietary Manager stated the fruit was watermelon cut the night before and said all food items should be labeled with the date made, use-by date, and employee initials. The Registered Dietician stated all food needed to be labeled and dated to identify the food and determine when it should be discarded. Mushrooms and a white liquid residue consistent with milk were also observed on the refrigerator floor. The Certified Dietary Manager stated nothing should be on the floor and expected it to be cleaned up. In addition, the sanitizer spray bottle used to clean food countertops tested at zero on a sanitizer strip, and the Dietary Aid stated it may have been water instead of sanitizer. The Certified Dietary Manager stated the sanitizer should normally test within the acceptable range and that improperly sanitized countertops were not acceptable.
Kitchen Drainage Air Gaps Not Maintained
Penalty
Summary
Essential kitchen equipment was not kept in safe operating condition when the food preparation sink did not have an air gap and the ice machine that supplied ice to residents also did not have an air gap. During a concurrent observation and interview with the Dietary Manager in the kitchen, the food prep sink was seen piped directly into the wall, and a drain on the floor beneath it had no piping going to it. The Dietary Manager stated the facility was not using an air gap and that the pipe from the food prep table went directly into the city sewer. During a concurrent observation and interview in the breakroom, the ice machine was observed with the hose hanging over the rim of the drain and passing below the level of the floor. The Dietary Manager stated this was the only ice machine in the facility and that there was no air gap for it. The Maintenance Director and Registered Dietician both stated the food prep sink and ice machine lacked the required air gaps, and the facility policy titled Drainage Air Gap Policy stated air gaps were required for drains in all areas of the facility, including ice machines, dish machines, and floor drains under sinks.
Incomplete Behavior Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that one of six sampled residents, Resident 10, was free from unnecessary psychotropic medication use when behavior monitoring was not attempted or implemented for haloperidol. Resident 10 was admitted with diagnoses including schizoaffective disorder, extrapyramidal and movement disorder, and chronic kidney disease. During observation, Resident 10 was ambulating with a front wheel walker, joined group activities, stated she was not sure how long she had been in the facility, and was observed with involuntary shaking of the hands. Record review showed Resident 10 had an order for haloperidol 7.5 mg twice daily for schizoaffective disorder, started on 11/22/25. Staff interviews indicated Resident 10 sometimes refused care and yelled at staff, and the LVN stated Resident 10 had physical and verbal aggressiveness toward staff. The LVN, MDSC, and DON all stated behavior monitoring should have been in place when the psychotropic medication was started, but the LVN did not find behavior monitoring for haloperidol and the MDSC stated the monitoring was incomplete. The facility policy stated psychotropic medication management includes adequate monitoring for efficacy and adverse consequences and that documentation must include attempted behavioral interventions.
Missing Dementia Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and implemented for one sampled resident with a diagnosis of dementia. During an initial tour, the resident was observed sitting at the edge of the bed with an oxygen concentrator at bedside and the nasal cannula placed in a plastic bag. The resident stated she had no complaints. The resident’s admission record listed diagnoses including dementia, schizoaffective disorder, and bipolar disorder, and the MDS assessment showed a BIMS score of 15 out of 15. During record review and interviews, an LVN stated she was familiar with the resident’s care and did not find a care plan initiated for dementia, and stated licensed nurses were responsible for ensuring care plans were initiated for residents’ diagnoses. The MDSC also reviewed the record and stated the resident had a diagnosis of dementia since admission, but no care plan for dementia was found. The MDSC stated a care plan should have been initiated on admission and that the resident had other care plans that were not focused on dementia. The DON stated licensed nurses were responsible for developing care plans, that care plans should be individualized and specific to resident needs, and that the MDSC was responsible for ensuring care plans were in place when completing MDS assessments. The facility policy stated the comprehensive, person-centered care plan is developed within seven days of completion of the required MDS assessment and no more than 21 days after admission.
Clozapine Order Summary Did Not Match Prescribed Dose
Penalty
Summary
The facility failed to maintain professional standards of practice for one resident with diagnoses including schizoaffective disorder, bipolar type, and anxiety disorder when the resident’s clozapine orders did not match. The resident’s Order Summary Report showed three clozapine orders totaling 175 mg, including 100 mg, 25 mg, and 50 mg tablets, but the summary on the 50 mg order stated to give the medication with a total dose of 150 mg. During interview, RN 2 acknowledged the summary stated 150 mg when the resident was supposed to be on 175 mg, and RN 1 stated the mismatch could be confusing to a nurse unfamiliar with the order. During observation, the resident’s clozapine blister packs were reviewed, and RN 2 stated the packs should have had an orange sticker to alert nurses to a medication order change. RN 1 stated the resident’s clozapine dose had been increased from 150 mg to 175 mg and nurses needed to double check the order to ensure the resident did not receive the wrong dose. The DON stated all dosage information in the resident’s medication orders should match, and matching the dosage information with the summary helped eliminate the chance for potential medication administration errors.
Failure to Provide Nail Care and ADL Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs was provided to maintain personal hygiene and grooming for two sampled residents, both of whom had long, jagged fingernails with discolored or dark particles under the nails. During the initial tour, one resident was observed lying in bed with the TV on and stated the resident did not remember the last time the fingernails were trimmed, though the resident did not mind the long nails as long as they had smooth edges. The resident’s AR listed diagnoses including Alzheimer’s disease, dementia, and anxiety, and the MDS showed a BIMS score of 15 out of 15, indicating no cognitive deficit. Another resident was observed lying in bed watching TV and had long, jagged fingernails with dark colored particles under the nails. The resident stated the nails caused scratching, especially during showers, and expressed concern about developing an infection. The resident also stated not remembering the last time the fingernails were cut or trimmed and reported being unable to move the left side after a stroke. The resident’s AR listed diagnoses including hemiplegia, hemiparesis, DM, and hypertension, and the MDS also showed a BIMS score of 15 out of 15. During interview and record review, a CNA stated the residents’ fingernails were long and jagged, that one resident had refused nail care, and that the nails should at least have been filed and reported to the licensed nurse when care was refused. The CNA stated nail care was scheduled on shower days and every Sunday. An LVN stated nail care was scheduled every Sunday, that one resident was diabetic and sometimes refused nail care, and that long fingernails could lead to scratching and breaks in the skin. The DON stated CNAs were expected to check fingernails on shower days, licensed nurses were responsible for diabetic residents’ nails, and nail care was also scheduled every Sunday. Facility documents showed CNAs were to assist with nail care, charge nurses were to monitor nursing care, and the facility policy required regular cleaning and trimming of nails, documentation of refusals and interventions, and notification of the supervisor if care was refused.
Inappropriate Use of Antipsychotic Medication in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs when the resident was prescribed and received an antipsychotic medication, Quetiapine, which carries a black box warning for increased mortality in elderly patients with dementia-related psychosis. The resident, who was admitted with diagnoses including anxiety, unspecified dementia with behavioral disturbance, and type 2 diabetes mellitus, was prescribed Quetiapine for the treatment of dementia-related behaviors such as restlessness, inability to sleep, and voiced sadness. However, the medication was not approved for the treatment of dementia-related psychosis, and there was no documented diagnosis or indication of use for this medication in the resident's discharge instructions from the hospital. Observations and interviews revealed that the resident was calm and did not exhibit any behaviors during the day, according to a certified nursing assistant who provided care. The resident's care plan and medication administration records indicated that the resident was not being monitored for hallucinations, delirium, or symptoms of psychosis, despite being prescribed an antipsychotic medication. The facility's staff, including a licensed vocational nurse, social services director, and director of nursing, acknowledged that the diagnosis of dementia was not an appropriate indication for the use of Quetiapine, and the facility's policy required that psychotropic medications be clinically indicated to treat a specific condition. The facility's policy and procedure on psychotropic medication use emphasized that residents should not receive medications that are not clinically indicated and that non-pharmacological approaches should be used to minimize the need for medications. The resident's physician stated that the medication was used off-label for behaviors and believed it was a good idea to continue the medication following hospital discharge orders. However, the physician also acknowledged that the medication was discontinued based on his assessment of the resident. The facility's failure to ensure appropriate use of psychotropic medication placed the resident at risk for adverse reactions and increased mortality.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent accidents, resulting in a resident eloping from the facility. The incident occurred when the resident, who was cognitively intact and had a history of elopement risk, managed to remove the lock from the sliding door in their room and left the facility unsupervised. This breach in security led to the resident being found and taken to the emergency room the following day. Interviews with various staff members, including the Director of Nursing, a mental health worker, a licensed vocational nurse, a maintenance assistant, and a certified nursing assistant, revealed that the sliding doors in residents' rooms were supposed to be locked at all times. However, the locks were simple to remove, and the maintenance assistant admitted that the sliding doors were only checked during monthly inspections, which were not documented. The facility's policy required the maintenance department to keep the building safe and free from hazards, but this was not effectively implemented. The resident's medical history included schizoaffective disorder, depression, and a need for assistance with personal care. The resident was admitted to the facility with a care plan indicating a risk for elopement due to involuntary placement and a history of substance abuse. The facility's policies on maintenance and elopement prevention were not adequately followed, leading to the resident's unauthorized departure and subsequent emergency room visit.
Resident Elopes Due to Inadequate Door Security
Penalty
Summary
The facility failed to provide a safe environment for a resident who eloped from their room through a sliding door that should have been securely locked. The incident occurred when the resident, who was cognitively intact and had a history of mental health issues, managed to remove the lock on the sliding door and leave the facility unsupervised. This resulted in the resident being taken to the emergency room the following day. Interviews with various staff members, including the Director of Nursing, a mental health worker, a licensed vocational nurse, a maintenance assistant, and a certified nursing assistant, revealed that the sliding doors in residents' rooms were expected to be locked at all times. However, the locks were simple to remove, and the maintenance assistant noted that while the locks were tightened with pliers, they could loosen over time. The sliding doors were checked monthly, but this was not documented on the maintenance checklist. The facility's policies and procedures emphasized the importance of maintaining a safe environment and preventing elopement, particularly in a mental health setting. Despite these policies, the resident was able to elope, highlighting a failure in the facility's safety measures and supervision protocols. The resident's medical records indicated a history of mental health disorders and substance abuse, which contributed to their risk of elopement.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer in the sacral region. The resident was admitted on 04/14/2023 and had an order for daily wound care, which included cleansing the coccyx wound, packing it with collagen powder, and covering it with calcium alginate and a foam dressing. During an observation of wound care, an LVN did not perform hand hygiene after cleaning the resident's wound and before applying medication and a clean dressing. Additionally, the LVN did not change gloves or perform hand hygiene between cleaning a second wound and applying medicated cream. Interviews with the LVN, Infection Preventionist, DON, and Administrator confirmed that the LVN did not follow the facility's hand hygiene policy. The LVN acknowledged that she should have cleaned her hands after each wound cleaning and before applying medications and dressings. The Infection Preventionist and DON stated that the nurse's actions could lead to the transmission of infection due to wearing dirty gloves during clean procedures. The Administrator also emphasized the importance of hand hygiene in preventing the spread of infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Atwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franciscan Post-acute Care Center | 6.8 mi | ★★★★★ | 3 | 0 |
| Golden Merced Care Center | 7 mi | ★★★★★ | 2 | 0 |
| Merced Nursing & Rehabilitation Ctr | 7.1 mi | ★★★★★ | 2 | 0 |
| La Sierra Care Center | 7.1 mi | ★★★★★ | 16 | 0 |
| Anberry Post Acute | 7.1 mi | ★★★★★ | 0 | 0 |
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