Complete Care at Nazareth LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Nazareth LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 10, 2026

  Based on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 2 of 3 residents (R2 and R1) reviewed.On 5/12/26, the facility substituted Brussels sprouts for carrots at the evening meal, without the approval of CD G (Clinical Dietician.) Brussels sprouts were served whole to resident R2 and R1, despite having mechanical soft diets.R2 had a choking episode and was sent to the emergency room (ER) for evaluation.R1 had a choking episode and was sent to the ER for evaluation. […]

• Immediate jeopardy, isolatedF689Sep 30, 2024

  Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 4 of 5 residents (R1, R2, R3, and R5) reviewed for wandering and elopement potential. R1 is severely cognitively impaired and has an Activated Power of Attorney for Health Care (APOAHC). R1 eloped from the facility on [DATE] and fell outside the facility, resulting in a fracture of his jaw. The facility did not have adequate supervision to ensure they were aware of R1's whereabouts and did not have security measures and monitoring in place to ensure R1 could not access various locations in the building, allowing him to exit the rear of the facility. […]

• Immediate jeopardy, isolatedF686Jul 20, 2023

  Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening, or to promote healing of PIs for 1 of 3 residents (R1) reviewed for PIs out of a sample of 17 residents. R1 was admitted to the facility without a pressure injury and was identified to be at risk for development of PIs. On [DATE] and [DATE], the facility identified that R1 had a reddened area on his sacrum and gluteal cleft. The facility did not notify R1's physician, obtain a treatment order, or monitor the reddened area. On [DATE], a Certified Nursing Assistant (CNA) discovered an open blood blister on R1's right buttock that was draining. The CNA reported this to LPN T (Licensed Practical Nurse). […]

• Actual harm, isolatedF689Sep 13, 2022

  Based on observation, interview, and record review, the facility did not provide adequate supervision and assistive devices to prevent accidents for 1 (R69) of 3 residents reviewed for falls out of a total sample of 20 residents. R69 sustained a subarachnoid hemorrhage, a T1 spinous process fracture, T2 vertebral body fracture, and two rib fractures when the facility failed to complete R69's walking program as care planned and recommended by therapy, failed to have an RN assess R69 after multiple falls, and failed to provide adequate supervision to keep R69 from falling again after multiple falls in one day. […]

• Actual harm, isolatedF697Sep 13, 2022

  Based on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 5 residents (R119) reviewed for pain. R119 was admitted to the facility following an intertrochanteric femur fracture (hip fracture). The facility did not provide R119 with physician ordered [MEDICATION(S)] for over 15 1/2 hours. Subsequently, R119 was experiencing severe uncontrolled pain and the facility failed to consult with R119's Physician. In addition, the facility does not have a documented pain goal for R119. Evidenced by: The facility policy, Pain - Clinical Protocol, updated 3/8/22, indicates in part the following: Assessment and recognition: 1. […]