Sweet Memorial Nursing Home

In the surveyor’s words

From the most serious findings on record at Sweet Memorial Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF692Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to routinely monitor and document a resident's weight in the resident's record, failed to ensure comprehensive quarterly nutritional assessments were completed timely to analyze and evaluate related factors for a severe weight loss, and failed to revise a residents care plan to prevent an avoidable weight loss for 2 (#s 15 and 20) of 20 residents sampled. Resident #15 had a severe 9.75% weight loss in the last three months, and 17% in the last six months. Resident #20 had a severe 6% weight loss in 29 days, and a severe 8% weight loss of her body weight in 92 days. This deficient practice had the potential to affect all residents at risk for nutritional deficit. Findings include:1. […]

• Actual harm, isolatedF689Dec 7, 2022

  Based on observation, interview, and record review, the facility failed to prevent a resident from eloping and wandering the facility from the facility for 1 (#12) failed to implement interventions for #12's wandering behaviors causing resident's to be upset, for 2 (#s 12 and 15) of 4 sampled residents. Findings include: Review of a facility reported incident regarding resident #12, dated 6/3/22, showed, Facility under COVID outbreak lockdown since Tuesday 5/31/22. Residents are all a little out of sorts being isolated to their rooms. Also, this resident is normally quite busy and does roam around the facility, occasionally trying to open the doors. […]

• Actual harm, isolatedF600Sep 2, 2021

  Based on interview and record review, the facility failed to protect 1 (#32) from resident to resident abuse with injury by resident (#82); failed to protect 1 (#7) from alleged abuse with injury; and failed to protect 1 (#00) from neglect, of 5 sampled and supplemental residents. Findings include: 1. Record review of resident #82's Care Plan, dated 2/14/20, showed a concern for: Behavioral Symptoms: Angry outbursts, inappropriate physical behavior and inappropriate verbal behavior. Evidenced by: No concept of what is dangerous, left family while on a (sic) outing and ended up hurt and in jail. Punched a CNA in the face while trying to elope. Curses and yells at residents and staff. Threatened resident that he would kill her after she provoked him . […]

• No harm, potential for more than minimal, widespreadF880Dec 6, 2023

  Based on observation, interview, and record review, the facility staff failed to complete proper hand hygiene during resident medication pass, properly wear masks during a facility outbreak of COVID-19, and sanitize a mechanical lift after resident use, prior to storing. This deficient practice has the potential to spread infection to all residents in the facility. Findings include: During an observation and interview on 12/5/23 at 8:46 a.m., staff member R was observed passing medication to multiple residents without performing hand hygiene between residents. Staff member R said she knows she was not good about performing hand hygiene and should be either hand sanitizing or doing a full wash with soap and water. […]

• No harm, potential for more than minimal, widespreadF881Dec 6, 2023

  Based on interview and record review, the facility failed to have an antibiotic stewardship program in place. This deficient practice had the potential to affect all residents residing in the facility. Findings include: During an interview on 12/4/23 at 2:06 p.m., staff member A stated the facility was in outbreak status for COVID-19. Staff member A stated no residents tested positive, but one staff member was positive. During an interview on 12/4/23 at 3:06 p.m., staff members A and B stated they would be the back up for the infection prevention program. Staff members A and B were unsure how staff member H was tracking antibiotics, or what kind of criteria or programs she used. […]