Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Anchorage Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including morbid obesity, DM II, Stage 5 CKD, prior CVA with left-sided weakness, dementia, and other comorbidities, experienced a significant weight loss of 7.9% in one month as documented in the EMR. Facility policy required immediate notification of the resident, the practitioner, and the resident’s representative for significant changes in condition, such as this weight loss. The EMR generated a significant weight change alert, but another staff member cleared the alert, and department managers and the resident’s physician were not promptly informed of the change, resulting in a failure to provide required notification.
A resident with multiple comorbidities and an order for weekly skin assessments developed a new open area under the left great toenail that was initially identified and reported, with wound care orders put in place. However, required follow-up assessment tools were not completed, weekly skin integrity reviews for several weeks documented either no skin issues or lacked any detailed assessment of the toe wound, and the care plan was not updated to address the non-pressure wound. Later, an RN found the toe swollen, red, warm, tender, with the toenail and surrounding skin detached and dark discoloration of the toes; a CRNP then assessed a full-thickness infected wound with exposed subcutaneous tissue and moderate serosanguineous drainage. The resident was transferred to the hospital, where the wound was associated with MRSA bacteremia and the resident subsequently underwent a left below-knee amputation.
The facility failed to maintain firmly secured handrails on two of four floors, despite a maintenance policy and a high-priority work order noting needed repairs. Surveyors observed long sections of hallway handrails on the second floor detached from the wall and additional unsecured and missing handrails on the third floor. A CMA and the Resident Council President reported the handrails had been unrepaired for several months and noted that some residents rely on them for safety. The Maintenance Director and NHA both acknowledged awareness of the problem, with the NHA citing delays in obtaining materials as a reason repairs had not been completed.
A resident with acute and chronic respiratory failure, OSA, and severe obesity was readmitted from the ED after severe hypoxia requiring BIPAP and aggressive diuresis. The facility physician documented the need for pulmonary follow-up and possible PFT and CPAP, and later stated he had communicated to nursing that the resident required a pulmonary test and CPAP. The resident’s care plan addressed altered respiratory status and OSA and directed staff to report abnormal findings and monitor vitals. However, due to miscommunication between the physician and nursing staff, no CPAP order was written or processed, despite facility policy requiring timely handling of physician orders. The resident’s cause of death was recorded as congestive heart failure.
A cognitively intact resident with an order for turning and repositioning every 2 hours for wound management had multiple missed entries on the TAR where the intervention was not signed as completed. The care plan required encouraging or assisting the resident to turn and reposition and ensuring this was done. The resident reported prior concerns about not being turned every 2 hours. An LPN and an RN stated they performed the turning and repositioning but forgot to document it, and the DON and Administrator confirmed that staff were expected to document treatments and interventions at the time of care.
A resident with an abnormally high WBC count and on an NPO diet was not properly monitored or reported when a change in condition and an incident occurred. The facility failed to notify the physician and resident representative, and did not document the events as required by policy.
A resident with swallowing difficulties and on an NPO diet was found with a grape ice pop in their mouth, but staff did not document a change in condition or monitor for aspiration. Additionally, an abnormally high WBC count was not addressed or followed up with appropriate documentation or assessment.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and representative after a significant change in condition, specifically a significant weight loss. The facility’s policy on Notification of Change in Condition requires informing the resident, consulting with the resident’s medical practitioner, and/or notifying the resident’s representative or authorized family member when there is a significant change in the resident’s physical, mental, or psychosocial condition, including deterioration in health or clinical complications. During a complaint survey, it was determined that this policy was not followed for one resident. The complaint alleged that this resident was not provided with quality of care, prompting review of administrative documents, a closed medical record, and staff interviews. The resident involved had multiple diagnoses, including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, prior stroke with left-sided weakness, polyneuropathy, anemia in chronic kidney disease, hyperlipidemia, dementia, Vitamin D deficiency, GERD, and arthritis due to Lyme disease. A BIMS score obtained earlier showed severe cognitive impairment (6/15). Review of the resident’s record showed a weight of 199.3 pounds in early December and 183.0–183.5 pounds in early January, representing a 7.9% (15.8-pound) weight loss in one month. The facility dietician stated that the electronic medical charting system generates alerts to department managers for significant changes in condition, and that significant weight loss is an alert item. The resident’s significant weight loss was identified and confirmed, but another staff member cleared the weight loss alert, and as a result, department managers and the resident’s physician were not immediately made aware of the significant change in condition, constituting the cited deficiency.
Failure to Assess and Monitor Non-Pressure Toe Wound Leading to Infection and Amputation
Penalty
Summary
The facility failed to provide updated non-pressure wound assessments and failed to identify and monitor a new wound on a resident’s left great toe, resulting in delayed treatment for an infected wound. The resident had multiple diagnoses including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, stroke with left-sided weakness, and dementia, and had a physician order for weekly skin assessments to be documented every Monday. On 12/30/2025, a staff member alerted the unit manager LPN to a 0.5 cm open area under the resident’s left great toenail; the LPN observed the wound, documented the change in condition, and notified the physician and family. The physician ordered lab work, a venous doppler, and dressing care with betadine wet-to-dry dressings every shift. An assessment form completed that morning triggered a skin change in condition and indicated that a Braden Observation tool, Pain Observation tool, and Skin Grid (Pressure and Non-Pressure) tool should be completed and placed in the record, but there was no evidence that any of these three assessment tools were completed. Subsequent documentation failed to reflect ongoing assessment or monitoring of the left great toe wound. The doppler results reported on 12/31/2025 showed mild peripheral vascular disease in the left lower extremity without occlusion. However, review of the January Weekly Skin Integrity Reviews revealed no mention of the left great toe wound’s status, including any measurements or descriptions, for several weeks. On 01/05/2026, an LPN documented there were no skin areas; on 01/12/2026, another LPN documented there were no skin areas since the last skin check; and on 01/19/2026, an RN documented there was a skin area but did not attach an assessment of the left great toe. During this period, the resident’s care plan, which had previously identified risk for skin integrity issues, was not updated and no new care plan was initiated related to the non-pressure wound of the left great toe first identified on 12/30/2025. On 01/26/2026, an RN documented that the resident’s left great toe was swollen, red, warm, and tender, with the toenail no longer attached and the surrounding skin off, and areas of dark discoloration around the left toes. The RN notified the skin and wound consultant CRNP, who assessed the wound the same day. The CRNP documented that neither the resident nor facility nursing staff knew when the left great toe wound first appeared or what caused it, and described the toe as having the toenail removed with a large sheet of skin peeled off the entire distal toe. The CRNP’s wound assessment identified cellulitis and a new full-thickness wound measuring 2.1 cm x 6 cm x 0.3 cm with exposed dermis and subcutaneous tissue, unattached wound edges, and moderate serosanguineous drainage, though the resident denied pain. The CRNP cleansed and dressed the wound in preparation for transfer to the hospital, where the resident was later admitted for MRSA bacteremia secondary to a left foot wound and ultimately underwent a left below-knee amputation.
Failure to Maintain Secure Handrails on Resident Hallways
Penalty
Summary
Surveyors identified a deficiency related to unsecured and missing handrails on two of the facility’s four floors. The facility’s own “Policy for Facilities Maintenance Program” dated 8/12/2025 stated its purpose was to ensure a well-structured preventative maintenance program to promote safety and functionality. A work order created on 1/18/2026 by the administrator documented that handrails on the second floor needed attention and were assigned a high priority. Despite this, observations on 2/17/2026 and 2/20/2026 showed approximately a twelve-foot section of handrails on the second floor detached and unsecured from the wall. Further observation on the third floor showed an additional approximately five-foot section of unsecured and missing handrails. A CMA reported in interview that the handrails had not been repaired for several months and described them as a safety hazard. The Resident Council President stated the facility was aware the handrails had not been repaired for several months and explained that some residents depend on securing their hands on the handrails for safety. The Maintenance Director reported noticing the inoperable handrails upon being hired on 1/23/2026 and confirmed the facility was aware the second- and third-floor handrails were not secured, without knowing why repairs had not been completed. The Nursing Home Administrator acknowledged awareness that the handrails needed repair and stated that the supplier was taking too long to deliver the materials.
Failure to Obtain CPAP Order After Hospital Readmission for Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician’s recommended respiratory treatment, specifically a CPAP, was ordered and implemented for a resident readmitted from the hospital. The facility’s policy on General Physician Services states that the attending physician is responsible for managing the resident’s medical care and that care is based on the physician’s orders, including treatments and services. The resident was admitted with diagnoses of acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and obesity, and was dependent on staff for ADLs but cognitively intact with a BIMS score of 15/15. Nursing documentation shortly after admission noted diminished lung sounds bilaterally and that the resident preferred the head of the bed elevated to avoid shortness of breath, though no shortness of breath or need for supplemental oxygen was recorded at that time. The facility physician documented that the resident had presented to the ED with shortness of breath, was severely hypoxic, required BIPAP and aggressive diuresis, and was later transitioned to nasal cannula. In that same note, the physician concluded that the resident needed follow-up with pulmonary for possible PFT and possible CPAP. The resident’s care plan identified altered respiratory status related to respiratory failure and obstructive sleep apnea and directed staff to report abnormal findings to medical providers and monitor vitals. During interviews, the physician stated that, after reviewing the medical record and communicating with nursing staff, he informed nursing that the resident required a pulmonary test and a CPAP, and acknowledged that an order for CPAP should have been issued. The DON also stated there was miscommunication regarding the order and that the physician did not write it, despite facility policy requiring physician orders to be addressed in a timely manner. The resident’s cause of death was documented as congestive heart failure.
Failure to Accurately Document Turning and Repositioning on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete documentation on the Treatment Administration Record (TAR) for a resident who was readmitted to the facility and was coded as cognitively intact on a quarterly MDS. The resident had an order in January for turning and repositioning every 2 hours for wound management. Review of the January TAR showed multiple instances where this ordered intervention was not signed as completed, specifically on 01/02/2026 at 4:00 AM and 6:00 AM, 01/06/2026 at 6:00 PM, 01/10/2026 at 6:00 PM, and 01/28/2026 at 6:00 PM. The resident’s care plan dated 02/01/2026 included interventions to encourage or assist the resident to turn and reposition and to ensure the resident was turned and repositioned. During interviews, the resident reported having concerns in the past about not being turned and repositioned every 2 hours, although they stated that this had improved. An LPN and an RN who provided care to the resident each stated that they did turn and reposition the resident every 2 hours during their shifts, but both acknowledged they forgot to document these interventions on the TAR, with the LPN attributing this to getting busy with another resident. The DON confirmed that staff did reposition the resident every 2 hours but did not sign the TAR, and stated that staff were expected to document when treatments or interventions were completed. The Administrator also stated that the expectation was to document at the time of care so it would not be missed.
Failure to Notify Physician and Resident Representative of Change in Condition and Incident
Penalty
Summary
The facility failed to notify the physician and the resident's representative of a significant change in condition and an incident that potentially required physician intervention. Specifically, a resident had an abnormally high white blood cell (WBC) count, which was not reported to the physician or the resident's representative, and no change of condition report was initiated. Additionally, the resident, who was on an NPO (nothing by mouth) diet due to difficulty swallowing, was found with a grape ice pop in hand and a large piece in the mouth. This incident was not documented as a change in condition or incident, and neither the physician, nurse practitioner, nor the resident representative was notified. A review of the facility's policies indicated that nurses are responsible for reviewing and reporting abnormal lab results and significant changes in condition to the appropriate parties, including the physician and resident representative. The Director of Nursing confirmed that these notifications and required documentation were not completed for the resident in question. The failure to follow established protocols for notification and documentation led to the deficiency identified during the complaint survey.
Failure to Address Abnormal Lab Result and Monitor NPO Resident After Oral Intake
Penalty
Summary
The facility failed to address an abnormal laboratory result and did not monitor a resident for signs of aspiration following an incident that may have required physician intervention. Specifically, a resident with a history of difficulty swallowing and who was on an NPO (nothing by mouth) diet was found with a grape ice pop in their hand and a large piece in their mouth. Despite this, there was no documentation of a change in the resident's condition or initiation of monitoring for aspiration. Additionally, the resident's medical record showed an abnormally high white blood cell (WBC) count, which is significant for identifying infection or inflammation, but the facility did not document any response to this abnormal result or a change in the resident's condition. The lack of documentation and monitoring occurred despite the resident's known risk factors and the presence of clinical indicators that warranted further assessment.
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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 Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deer's Head Center | 1.3 mi | — | 10 | 0 |
| Wicomico Nursing Home | 1.3 mi | — | 13 | 0 |
| Bay Harbor Post Acute Healthcare Center | 1.5 mi | — | 15 | 2 |
| Delmar Nursing & Rehabilitation Center | 6.5 mi | — | 4 | 0 |
| Manokin Nursing And Rehab | 12 mi | — | 44 | 2 |
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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.