Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anchor Post Acute during CMS and state inspections, most recent first.
Unclean kitchen floor and food service equipment were observed during a kitchen inspection. The floor behind the ovens had accumulated food and debris, and multiple items stored for use were dirty, including two ovens, three stove top spill pans, a reach-in freezer, rolling cart shelves, a manual can opener, metal racks, and food prep pans. The RD confirmed the items were unclean and noted dietary staff were expected to keep kitchen equipment clean per the cleaning schedule and as needed.
A resident with a nephrostomy tube, hydronephrosis, and AKI had a care plan that addressed urinary complications but did not specify the actual care required for the nephrostomy tube. The MDS showed moderate cognitive impairment, and both a CNA and the MDSC confirmed the tube was present and should have been included in the care plan.
A resident with chronic respiratory failure, COPD, depression, adult failure to thrive, and severe cognitive impairment required maximal staff assistance for personal hygiene, including nail care. Facility policy called for regular nail cleaning, and the resident was scheduled for showers twice weekly, but repeated observations showed dark material under all fingernails and that the nails needed care. Staff interviews confirmed the resident was confused, compliant with nail care, and that nail care was to be provided during showers and as needed.
Two residents receiving oxygen had their flow rates set above the physician-ordered amount, and one resident’s oxygen machine and filter were visibly dirty. One resident had COPD and chronic respiratory failure with severe cognitive impairment, while the other had CHF and COPD. Staff interviews confirmed the incorrect oxygen settings and, for one resident, the lack of recent cleaning documentation for the oxygen filter.
A resident with anxiety-related diagnoses missed scheduled Clonazepam doses because the medication was not available in the facility. The MAR and staff interviews showed the pharmacy did not deliver the refill in time, resulting in missed doses, increased anxiety, and the need for a stat Ativan dose while the resident waited for the medication to arrive.
Meals Served Cold and Unpalatable: Four cognitively intact residents reported that meals were often cold, inconsistent, or did not taste good, with breakfast items such as eggs, toast, grits, and pancakes served barely warm. During a breakfast tray observation, staff served meals on unheated plates while the plate warmer was off, and the RD confirmed the test tray food was below hot-serving temperature.
Failure to use PPE during EBP: CNA entered a resident’s room multiple times to provide direct care without wearing PPE, despite the resident having a nephrostomy tube and being on EBP. The resident’s record showed a nephrostomy tube related to hydronephrosis and AKI, and the DON acknowledged that staff were to wear PPE for direct care under EBP. CDC guidance reviewed by surveyors stated that gowns and gloves are the minimum PPE for high-contact care activities under EBP.
The facility failed to securely store medications, as observed with two unlocked and unattended medication carts on Hall 400. One cart had a bottle of Clear Lax, and another had both a bottle of Clear Lax and a medicine cup with applesauce and pills. An LPN stated the cart was left unlocked due to being called away, contrary to facility policy requiring carts to be locked when not in use.
The facility failed to maintain proper kitchen hygiene and cleanliness of the ice machine, potentially affecting 105 residents. An inspection revealed a pink substance in the ice machine and improper handwashing by Cook1, who also did not wear a beard guard. The Dietary Manager confirmed the ice machine should be cleaned daily and that proper hand hygiene and beard guards are required.
The facility failed to serve palatable and properly heated food, as reported by five residents. They noted that hot foods were served cold and lacked seasoning, with food sitting in hallways before being served. Observations confirmed that food temperatures dropped significantly by the time of service, and a CNA verified the lack of seasoning and moisture, making the food difficult to eat.
The facility failed to prevent cross-contamination during catheter care and did not ensure staff wore appropriate PPE for residents on enhanced barrier precautions. A CNA did not change gloves or perform hand hygiene after providing catheter care, and staff did not wear gowns while caring for residents with surgical wounds, kidney failure, and gastrostomy tubes, despite signage indicating the need for gowns and gloves. Interviews revealed a lack of understanding and inconsistent application of EBP protocols.
A facility failed to assess a resident for self-administration of eye drops, as required by their policy. The resident, who was cognitively intact, had been keeping eye drops at their bedside for years without a documented order or assessment for self-administration. An LPN confirmed the absence of such an order, and the resident explained that the drops were left at the bedside due to nurses forgetting them. This oversight posed a potential risk to the resident's medication safety.
A resident reported missing money and a stolen hamper, but the facility failed to resolve the grievances in a timely manner, taking over a month to address the issues. The Social Services Director was initially unaware of the missing hamper, and the investigation into the missing money involved attempts to contact the resident's daughter and POA. The Administrator expected grievances to be resolved within 72 hours, but the process took significantly longer.
A resident with hemiplegia and hemiparesis reported feeling intimidated by a CNA, who discouraged the use of the call bell. The resident's family confirmed the CNA's behavior, leading to a request for the CNA's reassignment. The facility's grievance log did not reflect the incident, and the CNA was not removed from care but reassigned. The facility's leadership was unaware of the abuse concerns, and no further resident interviews were conducted.
A facility failed to report an allegation of verbal abuse involving a cognitively intact resident to the SSA. The resident's family reported that a CNA spoke rudely to the resident, and the family requested the CNA be removed from care duties. The incident was reported to the ADON but was not logged in the Grievance Log or reported to the SSA, as it was considered a customer service issue.
A facility failed to investigate an abuse allegation involving a resident who was cognitively intact. The incident involved a CNA speaking rudely to the resident, which was reported to an LPN and ADON but not documented or investigated according to policy. The CNA was not removed from resident contact, and no further interviews were conducted. The incident was not reported to the SSA and was treated as a customer service issue.
The facility failed to provide three residents and/or their representatives with written transfer notices containing required information, such as Ombudsman contact and appeal rights. Despite being transferred to the hospital for medical issues, the residents and their representatives did not receive proper notification, as confirmed by interviews and record reviews. The facility's documentation was inadequate, and there was no policy available for emergent transfers.
A resident at high risk for falls did not have a scoop mattress documented in their care plan, despite a physician's order. Observations revealed only one fall mat was present, contrary to the care plan's requirement for mats on both sides of the bed. Staff interviews confirmed the resident fell attempting to get out of bed, and the missing mat was being cleaned.
A facility failed to timely implement a gradual dose reduction for a resident's antipsychotic medication, Seroquel, despite a pharmacist's recommendation and physician's approval. The resident, diagnosed with psychosis, Wernicke's encephalopathy, and dementia, continued to receive the higher dose due to the physician not entering the order into the EMR. The ADON noted that signed recommendations were not reviewed, leading to the oversight.
Unclean kitchen floor and food service equipment
Penalty
Summary
The facility failed to ensure the kitchen floor and multiple pieces of food service equipment were kept clean. During the initial kitchen inspection, the floor behind the kitchen ovens was observed to be unclean with accumulated food and debris, and the Registered Dietitian confirmed the area was unclean. The facility policy titled Sanitation stated that the food service area shall be maintained in a clean and sanitary manner and that all utensils, counters, shelves, and equipment shall be kept clean. During the same inspection, several items stored and ready for use were observed to be unclean, including the interior cooking compartments of two ovens with dried and burned food spills and debris, three stove top spill pans with heavy dried and burned food and debris, the interior bottom of one reach-in freezer with brownish ice, shelves on two metal rolling carts with dried food substance and loose debris, the shelves on a metal rolling cart holding sheet pans with dried food substances and loose debris, a large manual can opener with dried substances on its blade and base attachment, and five 24-cavity food preparation pans with greasy residues and/or burned-on substances. The RD confirmed all of the observed kitchen equipment was unclean and stated dietary staff were expected to keep kitchen equipment clean as scheduled and as needed.
Incomplete Care Plan for Nephrostomy Tube
Penalty
Summary
Failure to develop and implement a complete care plan for R1 included not addressing the care required for the resident’s nephrostomy tube. R1 was admitted with diagnoses including a nephrostomy tube since 2022 due to hydronephrosis and acute kidney injury with tubular necrosis. The admission MDS dated 09/01/25 showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The comprehensive care plan initiated on 08/30/25 and revised 09/05/25 identified R1 as at risk for complications with the urinary system related to having a right-sided nephrostomy and included goals and interventions related to urinary device complications, medications, fluids, labs, physician notification, and urology/nephrology follow-up. However, the care plan did not specify what type of care was required for the nephrostomy tube. A CNA confirmed that R1 had a nephrostomy tube, and the MDS Coordinator agreed that the care for the nephrostomy should have been included in the care plan.
Failure to Provide Fingernail Care and ADL Assistance
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for ADL assistance received fingernail care and bathing services. The resident had diagnoses including chronic respiratory failure, COPD, depression, and adult failure to thrive, and the care plan identified a risk for ADL and mobility decline with interventions for staff to assist with bathing and hygiene as needed. The quarterly MDS showed severe cognitive impairment with a BIMS score of 7 out of 15 and indicated the resident required maximal staff assistance for personal hygiene, including nail care. The facility policy on fingernails/toenails stated nail care includes daily cleaning and regular cleaning. The shower schedule showed the resident was to receive showers twice weekly. However, observations on three separate occasions showed dark brown material under all fingernails and that the fingernails needed care. During interviews, a CNA and an LPN stated the resident was confused, compliant with fingernail care, and that staff provided nail care during showers and as needed. The DON stated staff were to provide fingernail care during showers and that CNAs were to assess fingernails every shift and provide nail care as needed.
Incorrect Oxygen Flow and Unclean Oxygen Equipment
Penalty
Summary
The facility failed to ensure two residents receiving oxygen therapy received it at the physician-ordered flow rate and that one resident’s oxygen equipment was clean and sanitary. R63 was admitted with chronic respiratory failure and COPD, had an order for oxygen at 2 lpm continuous via nasal cannula, and had severe cognitive impairment with a BIMS score of 7 out of 15. However, observations on two separate occasions showed R63’s oxygen rate set at 3.5 lpm, and the oxygen machine had a film of gray dust on the outside with visible dust on the filter. Staff interviews confirmed the oxygen rate was incorrect and that the machine and filter did not appear to have been recently cleaned, and the nursing supervisor could not locate documentation that the filter had been cleaned. R15 was admitted with congestive heart failure and COPD and had an order for oxygen at 2 lpm continuous via nasal cannula with the oxygen machine filter to be cleaned every Sunday. Although the MAR documented oxygen at 2 lpm and weekly filter cleaning, observations on two occasions showed R15’s oxygen rate set at 4 lpm. An LPN stated he had not yet checked R15’s oxygen rate during his shift and confirmed it was incorrectly set above the physician’s order. The DON stated nurses were to check oxygen rates every shift and ensure residents received oxygen per physician orders.
Medication Not Available for Scheduled Anti-Anxiety Doses
Penalty
Summary
The facility failed to have Clonazepam available for administration for one resident with diagnoses of bipolar disorder, anxiety disorder, and major depressive disorder. The resident had a BIMS score of 15 of 15 and was documented as cognitively intact. Her care plan identified a need for anti-anxiety medication related to anxiety disorder, and the physician ordered Clonazepam 1 mg by mouth twice daily for anxiety. Review of the September 2025 MAR showed the resident did not receive her scheduled Clonazepam doses on two days because the medication was not available in the facility. The MAR documented that the 9:00 AM doses were missed on both days due to the medication not being available. Progress notes showed the Clonazepam order had been refilled, then refilled again after pharmacy request, and staff contacted the pharmacy when the medication was not delivered. During interviews, the resident stated she went without Klonopin for two or three days and experienced sweating and increased anxiety, and she reported receiving Ativan on the afternoon of the second day when the facility could not obtain the medication. The LPN confirmed the missed doses occurred because the medication was not available from the pharmacy, and the DON confirmed four doses were missed because the medication was not available in the facility. The DON stated the refill had been submitted too early, so the pharmacy did not dispense it because insurance would not reimburse at that time, and the facility did not have a policy for obtaining medications from its pharmacy.
Meals Served Cold and Unpalatable
Penalty
Summary
Food and drink were not served palatable, attractive, and at a safe and appetizing temperature for four of four residents reviewed for food palatability. The facility policy stated each resident is to receive a nourishing, palatable, well-balanced diet and that food and nutrition services staff will inspect trays to ensure the correct meal is provided, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Four cognitively intact residents, with BIMS scores ranging from 13 to 15, reported that meals were often cold or did not taste good. One resident stated food was not always hot and should be seasoned, another said breakfast items such as eggs and toast were always served cold and that trays sat on the hallway cart for long periods, another reported meals were inconsistent and cold when served, and another stated the food was cold at meals and that very few good meals were served. During a breakfast test tray observation, resident meals were served on unheated plates while the kitchen plate warmer was turned off. Although hot foods on the tray line were at acceptable temperatures of 135 degrees Fahrenheit and above, the test tray and other resident trays were placed on an enclosed cart with no heating element and delivered to the hallway. When the test tray was sampled later, the grits were 115 degrees Fahrenheit and barely warm, and the pancakes were 117 degrees Fahrenheit and barely warm; both had started to cool, and the Registered Dietitian confirmed they needed to be hotter. The last resident breakfast tray on the hallway was not served until 8:56 AM, and the RD stated the plate warmer should have been turned on before meal service and the grits and pancakes should have been hot when served.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when nursing staff failed to wear PPE while providing direct care to one resident reviewed for Enhanced Barrier Precautions (EBP). Observations on 09/09/25 at 10:30 AM showed a small black bag hanging on the side of the resident’s bed, and CNA3 confirmed at that time that the resident had a nephrostomy tube. Additional observations on 09/09/25 at 10:30 AM, 09/10/25 at 2:00 PM, and 09/11/25 at 10:00 AM and 3:00 PM showed CNA3 entering the resident’s room to provide direct care without wearing any PPE. Record review showed the resident was admitted with diagnoses including a nephrostomy tube since 2022 due to hydronephrosis and acute kidney injury with tubular necrosis. The admission MDS dated 09/01/25 showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. During interview on 09/11/25 at 4:00 PM, the DON stated the IP was out of the facility and agreed that because the resident had a nephrostomy tube and was on EBP, nursing staff were to wear PPE when providing direct resident care. CDC guidance reviewed by surveyors stated that EBP include gown and glove use during high-contact resident care activities for residents with MDROs or at increased risk of MDRO acquisition, including residents with indwelling medical devices.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications and biologicals, as observed in two instances involving medication carts on Hall 400. During observations, an unattended and unlocked medication cart was found with a bottle of Clear Lax on top. In a subsequent observation, another unattended and unlocked medication cart was found with a bottle of Clear Lax and a medicine cup containing a mixture of applesauce and pills. An LPN explained that the medicine cup was left due to a resident refusing medication and that the cart was unlocked because she was called away. The facility's policy requires that medication carts be locked when not in use, and the Director of Nursing confirmed this requirement during an interview.
Deficiencies in Kitchen Hygiene and Ice Machine Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and proper hygiene in the kitchen, which had the potential to affect 105 residents consuming food from the facility. During an inspection, a light pink colored unknown substance was found inside the ice machine, and a bottle of Shasta ginger-ale was buried in the ice. The Registered Dietitian confirmed the presence of the pink substance and stated that the ice machine was cleaned weekly, although it had not been cleaned on the day of the inspection. The Dietary Manager later confirmed that the ice machine should be cleaned daily, and nothing should be placed in the ice. Additionally, Cook1 was observed cooking without a beard guard, despite having facial hair, and failed to follow proper handwashing procedures. Cook1 washed his hands for less than 20 seconds and turned off the faucet with his bare hand instead of using a paper towel. After washing, Cook1 touched his face and beard guard with a gloved hand before handling food, which violated the facility's policy on preventing cross-contamination. The Dietary Manager confirmed that beard guards were required in the kitchen and that proper hand hygiene should be practiced.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to serve food that was palatable and at an appetizing temperature, as expressed by five residents during a group interview. These residents reported that hot foods were served cold and lacked seasoning, specifically mentioning cold potatoes, lima beans, and grits. The residents noted that food sat in the hallways for at least 10 minutes before being served, contributing to the coldness. This issue was documented in the Resident Council Minutes over several months, indicating ongoing dietary concerns. Observations during a lunch meal tray line revealed that while initial food temperatures were within acceptable ranges, the temperatures dropped significantly by the time the food was served to residents. For instance, the pork loin with Dijon gravy, fried potatoes and onions, and lima beans were all served at room temperature. The Dietary Manager confirmed these low temperatures, and a Certified Nursing Assistant verified the lack of seasoning and moisture in the food, making it difficult to eat.
Inadequate Infection Control and PPE Usage
Penalty
Summary
The facility failed to prevent cross-contamination during catheter care for a resident with neuromuscular dysfunction of the bladder. During an observation, a CNA did not change gloves or perform hand hygiene after providing catheter care and handling soiled materials. The CNA continued to assist the resident without changing gloves, which is against the facility's policy for hand hygiene and catheter care. The resident had a history of Escherichia coli and Extended spectrum beta-lactamase, which necessitates strict adherence to infection control practices. Additionally, the facility did not ensure that staff wore appropriate Personal Protective Equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP). Observations revealed that staff did not wear gowns while providing care to residents with conditions such as surgical wounds, acute kidney failure, and gastrostomy tubes, despite signage indicating the need for gowns and gloves. Interviews with staff indicated a lack of understanding and inconsistent application of EBP protocols, with some staff believing gowns were only necessary for certain types of care or when infections were present. The Infection Preventionist confirmed that staff were trained on infection control measures, including the use of PPE and EBP protocols. However, there was a disconnect between training and practice, as evidenced by staff not following the guidelines during care. The facility's failure to enforce proper PPE usage and hand hygiene practices could contribute to the spread of multidrug-resistant organisms within the facility.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically eye drops, which was a requirement according to their policy. The policy stated that if it is deemed safe and appropriate for a resident to self-administer medications, this should be documented in the medical record and care plan, with periodic reassessment based on changes in the resident's medical or decision-making status. However, for the resident in question, there was no documented assessment or order for self-administration of the eye drops, despite the resident having a BIMS score indicating cognitive intactness and having kept the eye drops at their bedside for an extended period. During an observation, it was noted that the resident had three bottles of eye drops on their bedside table, and an LPN confirmed that there was no order for the eye drops to be kept at the bedside. The resident mentioned that they had been keeping the eye drops at their bedside since their admission six and a half years ago, as the nurses would often forget them. The resident also stated that they used to self-administer the drops but had not done so since their admission, and the facility had been administering them instead. This lack of assessment and documentation for self-administration of medication posed a potential risk to the resident's medication safety.
Delayed Response to Resident Grievances
Penalty
Summary
The facility failed to respond to a resident's grievances in a timely manner, as required by their policy. The policy stated that grievances should be filed with the administrator within five working days and that the resident should be informed of the findings within a specified number of days. However, in the case of a resident who reported $40 missing and a stolen clothes hamper, the grievance was not resolved until over a month later. The resident initially reported the missing money on May 31, 2024, but the resolution was not reached until July 1, 2024. Interviews with the Social Services Director (SSD) and the Administrator revealed that the SSD was unaware of the missing hamper until July 1, 2024, and that the investigation into the missing money involved attempts to contact the resident's daughter and Power of Attorney (POA). The Administrator expressed an expectation for grievances to be resolved within 72 hours, but the Regional Nurse indicated that the time frame could vary depending on the investigation. The delay in resolving the grievance was confirmed by the SSD, who acknowledged that the grievance was filed on May 31, 2024, but not resolved until July 1, 2024.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse and intimidation by a Certified Nursing Assistant (CNA). The resident, who was cognitively intact and admitted with a diagnosis of hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, reported feeling afraid to use the call light due to the CNA's behavior. The resident's family member confirmed the incidents, stating that the CNA had told the resident to stop pressing the call bell and made intimidating remarks. The family member requested that the CNA no longer provide care for the resident, and this request was communicated to a Licensed Practical Nurse (LPN). The facility's grievance log did not reflect any concerns logged by the resident or their family, and the Social Services Director was unaware of any abuse concerns. The Administrator and Assistant Director of Nursing (ADON) also reported not receiving any complaints about staff-to-resident verbal abuse. However, the LPN stated that she had reported the incident to the ADON via text message, but did not document the incident or write a statement. The LPN did not remove the CNA from care but instead swapped her with another CNA to provide care for the resident. The Director of Nursing (DON) and ADON acknowledged that the family had reported the CNA as being loud, but they did not perceive it as rudeness. The CNA was not removed from care but was reassigned to other residents. The facility's Concern/Grievance Report noted that the CNA was removed from the assignment due to the resident's perception of loudness, and the family was reportedly satisfied with this intervention. No additional residents were interviewed to determine if they had similar experiences with the CNA.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the State Survey Agency (SSA) as required by their policy. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident's family member reported that a Certified Nursing Assistant (CNA) had spoken rudely to the resident, telling them to stop pressing the call bell and mentioning that other residents needed care. The family member addressed the issue with the CNA and requested that the CNA no longer provide care for the resident. This request was communicated to a Licensed Practical Nurse (LPN), who reported the incident to the Assistant Director of Nursing (ADON) via text message. Despite the report to the ADON, the facility did not log the concern in their Grievance Log, and the Social Services Director was unaware of any abuse concerns. The ADON and the Regional Nurse did not report the incident to the SSA, considering it a customer service issue rather than an abuse allegation. The facility's policy requires all reports of abuse to be reported to local, state, and federal agencies, but this protocol was not followed in this case, potentially contributing to further verbal abuse and possible psychosocial harm to the resident.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident, identified as R254, who was cognitively intact with a BIMS score of 15 out of 15. The incident involved a Certified Nursing Assistant (CNA1) who allegedly spoke rudely to the resident, telling them to stop pressing the call bell and mentioning other residents who were dying and needed care. The resident's family member reported the incident to a Licensed Practical Nurse (LPN1), who then informed the Assistant Director of Nursing (ADON) via text message. However, the incident was not documented in the facility's grievance log, and no formal investigation was initiated as per the facility's policy. The facility's policy requires that all allegations of abuse be thoroughly investigated, including reviewing documentation, interviewing witnesses, and removing the accused staff member from resident contact until the investigation is completed. In this case, the CNA was merely swapped out with another CNA to care for the resident, and no further interviews or investigations were conducted to determine if other residents had similar experiences with CNA1. The ADON and Regional Nurse did not report the incident to the State Survey Agency (SSA) and treated the issue as a customer service matter rather than a potential abuse case.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices containing the required information to three residents and/or their representatives. This deficiency was identified during a review of records and interviews with residents and staff. The lack of proper notification had the potential to affect the residents and their representatives by leaving them uninformed about the reasons for the transfer, the location of the transfer, and their rights to appeal the transfer. One resident, who was cognitively intact, was sent to the hospital for evaluation due to altered mental status. The facility provided two untitled forms as evidence of notification, but these forms lacked essential information such as the Ombudsman contact and appeal rights. The resident and her representative both stated they had never received these forms. Another resident, also cognitively intact, was transferred to the hospital twice due to medical issues. The facility again provided forms that were missing critical information, and both the resident and his representative confirmed they had not received any written notices. A third resident was transferred to the hospital for low blood pressure, and the facility's documentation did not show evidence of a written notice being provided. The Assistant Director of Nursing confirmed that the forms used did not contain all the required information. Despite the Director of Nursing's expectation that notices would be provided on the day of transfer, there was no policy available to guide emergent transfers, and the facility failed to provide adequate written notices to the residents and their representatives.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to prevent accidents for a resident by not implementing an intervention listed on the care plan. The resident, who was admitted with a diagnosis of hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, was assessed as high risk for falls. Despite this, the care plan did not document the use of a scoop mattress, which was ordered by a physician to prevent the resident from scooting down and getting out of bed. Additionally, the care plan indicated the use of fall mats on both sides of the bed, but during observations, only one fall mat was present. Interviews with staff revealed that the resident had a fall because she attempted to get out of bed herself, and it was confirmed that there was only one fall mat in the room. The Assistant Director of Nursing noted that the missing fall mat was being cleaned, which contributed to the lack of proper fall prevention measures. The failure to implement the scoop mattress intervention and ensure the presence of both fall mats as per the care plan had the potential to cause harm to the resident from a fall.
Failure to Implement Timely Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to conduct a gradual dose reduction (GDR) for a resident's antipsychotic medication, Seroquel, in a timely manner as recommended by the pharmacist. The resident, who had medical diagnoses including psychosis, Wernicke's encephalopathy, and dementia, was prescribed Seroquel for agitation. A recommendation for dose reduction from 50 mg to 25 mg was made by the pharmacist on 04/08/24 and signed by the physician on 04/11/24. However, the reduction was not reflected in the Medication Administration Record (MAR) as of 06/11/24, indicating a delay of over 60 days in implementing the GDR. The delay was attributed to the physician signing the recommendation but failing to enter the order into the electronic medical record (EMR). The Assistant Director of Nursing (ADON) explained that physicians are responsible for entering their own orders into the EMR. The signed pharmacy recommendations were sent to Medical Records to be scanned, but there was no process in place to ensure they were reviewed and acted upon, leading to the oversight.
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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 Aiken
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth- Aiken | 4.8 mi | ★★★★★ | 5 | 1 |
| Carlyle Senior Care Of Aiken | 4.8 mi | ★★★★★ | 8 | 2 |
| Aiken Rehabilitation And Care Center | 4.8 mi | ★★★★★ | 8 | 0 |
| Nhc Healthcare - North Augusta | 13.4 mi | ★★★★★ | 2 | 0 |
| Pruitthealth- North Augusta | 13.5 mi | ★★★★★ | 2 | 0 |
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