Nazareth Living Center

In the surveyor’s words

From the most serious findings on record at Nazareth Living Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 29, 2025

  Based on interview and record review, the facility failed to ensure one resident (Resident #4) received treatment and care in accordance with acceptable standards of practice when the facility failed to follow physician orders for a Prevena (wound vac, negative pressure wound therapy (NPWT) system used to manage closed surgical incisions) and the resident's wound dehisced (separation of the edges of a surgical wound, either partially or completely, due to failure of proper wound healing). Additionally, the facility failed to administer physician ordered medications and failed to notify the physician and resident representative (RR) that the medications and treatments were not administered. […]

• Actual harm, isolatedF689Oct 26, 2023

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #96) received appropriate supervision for wandering. The resident was admitted to the facility from the hospital on 7/26/23. The resident's hospital records showed the resident was found on 7/19/23, by a bystander, confused and wandering around his/her apartment complex. The resident was unable to tell Emergency Medical Staff (EMS) where he/she lived. The resident's family informed hospital staff the resident had been having progressive, worsening mental functioning and forgetfulness. The facility failed to ensure admission staff thoroughly read the hospital records and put elopement/wandering interventions in place upon the resident's admission. […]

• Actual harm, isolatedF684May 2, 2023

  Based on observation, interview and record review, the facility failed to ensure that a resident who admitted to the facility with intact skin, received treatment and care in accordance with professional standards of practice, when staff failed to provide timely skin assessments and monitoring for one resident (Resident #1). The resident admitted to the facility with known lower leg circulation issues and intact skin on 4/12/23. The facility did a skin assessment on 4/17/23, with no skin issues. On 4/28/23, the resident arrived at a scheduled appointment and upon voicing foot pain, the clinic removed the resident's socks. They assessed the resident's right foot had and observed 3 necrotic (dead, black tissue) toes and a wound in between the toes. […]

• Actual harm, isolatedF600May 10, 2021

  Based on interview and record review, the facility failed to ensure a resident was free from neglect by failing to ensure a staff member, contracted through an agency to provide goods and services to the residents, provided the services necessary to avoid physical harm. Certified Nursing Assistant (CNA) A failed to follow the resident's plan of care, the facility abuse and neglect policy and acceptable standards of practice for one resident (Resident #2) when he/she transferred the resident in a Hoyer lift (mechanical lift) without a second staff person to assist as required. The sample was 9. The census was 88. […]

• No harm, potential for more than minimal, widespreadF756Oct 26, 2023

  Based on interview and record review, the facility failed to ensure the pharmacist reports any irregularities to the attending physician and the facility's medical director and director of nursing, and ensure these reports were acted upon. In addition, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident for four of seven residents investigated for the monthly medication regimen review (Residents #65, #68, #48, and #8). […]