Anberry Post Acute

In the surveyor’s words

From the most serious findings on record at Anberry Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF692Mar 8, 2023

  Based on interview and record review, the facility failed to implement an effective process to ensure the maintenance of acceptable parameters of nutritional status and hydration for one of three sampled residents (Residents 1) when staff did not weigh Resident 1 weekly in accordance with facility policy and procedure, the recommendations and instructions provided by the Registered Dietician (RD) after identifying a risk for weight loss during the admission assessment, and again after weight loss had occurred, were not implemented by nursing staff. Staff did not notify the physician of Resident 1's decreased intake of food and fluids and weight loss until Resident 1 had experienced severe weight loss and was dehydrated. […]

• No harm, potential for more than minimal, widespreadF578Dec 13, 2024

  Based on interview and record review the facility failed to inform and provide written information on how to formulate an advance directive (a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness or injury) for 87 of 87 residents when staff did not document information on how to obtain an advance directive in resident charts. This failure violated the rights of 87 residents to be informed on how to formulate and obtain an advance directive. Findings: During an interview on 12/11/24 at 10:28 a.m. […]

• No harm, potential for more than minimal, widespreadF657Dec 13, 2024

  Based on interview and record review, the facility failed to revise and implement a person-centered comprehensive care plan (CP- road map for the care of a resident and a necessary tool in following the nursing process) for one of eight sampled residents (Resident 45) when the care plan was not updated to reflect discharge from hospice (end of life) service. This failure had the potential for Resident 45's needs to not be meet. Findings: During an interview on 12/10/24 at 9:38 p.m. in Resident 45's room with Family Member (FM) 1, FM 1 stated her mother was no longer on hospice services. During a concurrent interview and record review on 12/11/24 at 11:23 a.m. with License Vocation Nurse (LVN) 5, LVN 5 stated Resident 45 had been on hospice but was discharged from hospice on 11/16/24. […]

• No harm, potential for more than minimal, widespreadF658Dec 13, 2024

  Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of 16 sampled residents (Resident 46, Resident 231, Resident 233, and Resident 235) when: 1. Resident 46, Resident 231 and Resident 235's oxygen tubing were not labled with the date the tubing was changed. This failure put Residents 46, 231 and 235 at risk of infection. 2. The Attending Physician (AP) was not notified when Resident 233's medication for hypertension (high blood pressure) was not given due to low blood pressure levels. This failure put resident 233 at risk of harm due to low blood pressure levels. 3. […]

• No harm, potential for more than minimal, widespreadF732Dec 13, 2024

  Based on observation, interview, and record review the facility failed to ensure nursing staff information data posting contained or demonstrated the total numbers and actual hours worked by Registered nurses (RN), license vocational nurses (LVN) and Certified nurse aides, were posted daily. This failure resulted in 87 out of 87 residents and their family members not being able to identify who was responsible for their care, how many licensed and unlicensed staff were on shift, and the total number of hours staff were working. Findings: During an observation on 12/13/24 at 2:35 p.m. in the hallway, the Census and Direct Care Services Hours Per Patient Day (DHPPD) did not contain the total number of actual hours worked for RNs, LVNs and CNAs. During an interview on 12/13/24 at 3:04 p.m. […]