Zerbe Sisters Nursing Center,

In the surveyor’s words

From the most serious findings on record at Zerbe Sisters Nursing Center,, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 8, 2024

  Based on review of facility policies, facility documentation, clinical records and staff interviews, it was determined that the facility failed to protect residents from neglect for one of eighteen residents reviewed (Resident 47). Resulting in actual harm of skin tear and bruising to Resident 47. Findings include: The facility's policy Preventing Resident abuse revised April 2019, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. […]

• Actual harm, isolatedF760Apr 20, 2023

  Based upon review of facility policy and procedure, clinical records and documentation provided by the facility, it was determined that the facility failed to ensure residents were free from significant medication errors causing harm of hospitaization to one of eighteen residents reviewed (Resident 230). Findings include: Review of facility policy and procedure titled Medication Administration revealed The individual administering medications verifies the resident's identity before giving the resident his/her medications. […]

• No harm, potential for more than minimal, patternF921Aug 5, 2026

  Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, sanitary environment for three out of four residents (Residents R1, R2, and R3). Findings include: Observation on August 5, 2026, at approximately 10:00 a.m., in the Hearth Room common area finds an air conditioning window unit containing spots of a black, organic appearing substance within the air vent and on the plastic fins.Observation on August 5, 2026, at 10:40 a.m., in the room of Resident R1, reveals an air conditioning window unit with a moderate amount of spots of a black, organic appearing substance within the air vent and on the plastic fins.Observation on August 5, 2026, at 10:45 a.m., in the room of Resident R2, reveals an air conditioning window unit with a moderate to… […]

• No harm, potential for more than minimal, isolatedF689Feb 27, 2025

  Based on clinical record review, facility investigation review, and staff interview, it was determined the facility failed to ensure adequate supervision was provided during toileting transfer resulting in a fall of one of 20 residents reviewed (Resident 55). Findings include: A review of Resident 55's diagnosis list includes repeated falls, generalized weakness, abnormalities with gait and mobility, and Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 55's Quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in long-term care residents), dated December 11, 2024, revealed that the resident was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF755Feb 27, 2025

  Based on review of facility policy, observations, and interviews, it was determined the facility failed to document medication disposition for two of three discharged residents. (Resident 7 and Resident 76) Findings include: Review of facility policy titled Discarding and Destroying Medications, documents disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by resident. Disposal must be documented on the medication disposition record, with the signature of at least two witnesses. The medication disposition record will contain the resident's name, date medication disposed, name and strength of medication, name of dispensing pharmacy, quantity disposed, reason for disposition and signature of witnesses. […]