Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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.
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.
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 | — | 1 | 0 |
| La Sierra Care Center | 7.1 mi | — | 16 | 0 |
| Anberry Post Acute | 7.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.