Anberry Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Anberry Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for five of nine sampled residents (Residents 7, 8, 52, 63, and 92) when the Controlled Substance Record (CSR) and the Controlled Drug Record (CDR) (a mandatory document used for tracking drugs from the moment they arrive at a facility until they are given to a patient or destroyed, acting as a security measure to prevent theft or misuse) were not completed by the Licensed Nurses upon receipt from the pharmacy.These failures had the potential to result in compromised resident safety including medication errors and drug diversion (the illegal transfer of prescription… […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when:A pot with food and debris in it was stored in the clean area.A black bean veggie patty bag with one patty in it, in the walk-in freezer, was open and undated.The walk-in freezer fan had ice buildup on it. A plastic container in the walk-in refrigerator with sliced pink fruit inside was unlabeled and undated. A box of mushrooms and a box of celery was open and exposed to air in the walk-in refrigerator.Mushrooms and white liquid were observed on the walk-in refrigerator floor.The sanitizer spray bottle used for cleaning food countertops, contained water in it instead of the sanitizer. […]

• No harm, potential for more than minimal, widespreadF908Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when:The food preparation sink did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 2.The ice machine that supplies ice to the residents in the facility did not have an air gap. These failures had the potential to contaminate food sources for 90 of 97 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death.Findings:1. During a concurrent observation and interview on 1/20/26 at 3:05 p.m. […]

• No harm, potential for more than minimal, isolatedF605Jan 23, 2026

  Number of residents sampled: 6Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 10) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not attempt or implement behavior monitoring for Resident 10's use of haloperidol (medications used to treat schizophrenia [a mental illness that is characterized by disturbances in thoughts]).This failure placed Resident 10 at risk for experiencing adverse effects from receiving medication without behavior monitoring. During a concurrent observation and interview on 1/20/26 at 2:45 p.m. […]

• No harm, potential for more than minimal, isolatedF656Jan 23, 2026

  Number of residents sampled: 5Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of five sampled residents (Resident 2) when Resident 2 did not have a care plan for a diagnosis of dementia (a progressive state of decline in mental abilities).This failure placed Resident 2 at risk for harm by not identifying and monitoring signs and symptoms and care of resident with dementia. During a concurrent observation and interview on 1/20/26 at 10:15 a.m. […]