Anchor Care & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Anchor Care & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 30, 2024

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by their failure to ensure staff maintained a secure environment and implemented measures to mitigate the risk to prevent elopement for 1 of 1 resident reviewed for elopement, of a total sample of 5 residents, (#1). On 7/31/24 at approximately 7:48 PM, resident #1 left the facility unsupervised without the knowledge of staff. The resident walked along a busy roadway with a speed limit of 40 miles per hour and accepted a ride with strangers to get to her home. The facility staff were not aware of resident #1's whereabouts for approximately one hour and twenty minutes. […]

• Immediate jeopardy, isolatedF689Aug 30, 2024

  Based on interview, and record review, the facility failed to ensure the Admission process was thoroughly completed by accurately evaluating and providing needed supervision to prevent elopement for 1 of 5 residents at risk for elopement, of a total sample of 5 residents, (#1). On 7/31/24 at approximately 7:48 PM, resident #1 left the facility unsupervised without the knowledge of staff. The resident walked along a busy roadway with a speed limit of 40 miles per hour and accepted a ride with strangers to get to her home. The facility staff were not aware of resident #1's whereabouts for approximately one hour and twenty minutes. Due to her cognitive deficits, and diagnosis of dementia, the elopement placed her at risk of falling, being severely injured, abducted, or hit by a motor vehicle. […]

• Immediate jeopardy, isolatedF689Jul 9, 2021

  Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility, for 1 of 7 residents reviewed for elopement, out of a total sample of 8 residents, (#1). This failure contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a likelihood he could have fallen, become lost or been hit by a car. On 7/02/21 at approximately 5:55 PM, the facility failed to prevent resident #1 from exiting the facility through the front lobby door. Resident #1 stood by the unattended reception desk and a staff member unlocked the door for him at the request of another resident, without verifying his identity. […]

• Immediate jeopardy, isolatedF689Mar 2, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure vulnerable residents did not exit the facility unnoticed, failed to monitor exit doors to maintain a safe and secure environment, and failed to perform thorough elopement risk evaluations to establish appropriate and individualized safety interventions, for 1 of 19 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. […]

• Actual harm, isolatedF689Apr 1, 2022

  Based on interview and record review, the facility failed to provide necessary care and services as indicated in the plan of care to prevent an avoidable fall for 1 of 4 residents reviewed for mechanical lift transfers, of a total sample of 7 residents, (#1). The facility's failure to implement care plan interventions based on clinical assessment findings and accepted standards of practice resulted in actual harm, a fall with fracture. Findings: Resident #1, a [AGE] year-old female, was originally admitted to the facility on [DATE] and readmitted on [DATE]. […]