Nazareth Memory Center at Maria Joseph.

“The enabler bar on the side of resident 1's bed was not firmly secured to the mattress, moving approximately two to three inches back and forth, creating a safety hazard.”

“The dumpster lid was left open, allowing potential access by insects, rodents, and wild animals, creating a sanitation and pest control hazard.”

“Exit door 1 in the secured dementia care unit would not open when the correct code was entered into the keypad, preventing immediate egress in the event of an emergency.”

“The initial support plans for residents 2 and 3 listed the residents' designated persons in Part V but were not signed, and there was no indication that the designated persons were unable to or refused to sign.”

“Staff reported an allegation of abuse to the Administrator at 8:30 a.m., but the facility did not report it to the local area agency on aging until 10:41 a.m., failing to report immediately as required.”

“The facility did not report an incident to the Department's personal care home regional office within 24 hours; the report was submitted at 10:41 a.m. instead of the required timeframe.”

“Staff A allegedly slapped Resident's hand in the spa room after the resident inappropriately touched the staff member, resulting in a substantiated abuse allegation involving physical punishment.”

“Contracts for three residents were not signed by the residents themselves. The administrator, community liaison, and payer signatures were present, but the residents had not executed the contracts.”

“Resident Rights documents and contracts for three residents were not signed by the residents and, where applicable, their designated persons. No documentation of efforts made to obtain signatures was provided.”

“Two 8 oz. bottles of shampoo and body wash with external use warnings were found unlocked and accessible to memory care residents in an unlocked drawer in the men's main hallway bathroom at approximately 9:25 a.m.”

“Menus were only posted through 3/22/2025 at the time of inspection at approximately 9:22 a.m., rather than being prepared and posted one week in advance as required.”

“Staff member engaged in physical aggression towards a resident. The facility suspended the staff member pending investigation but failed to submit a plan of supervision or notice of suspension to the Department's regional office before allowing the staff member to return to work.”

“A staff member called a resident a derogatory term and told them they were evil, violating the requirement that residents be treated with dignity and respect.”

“The carbon monoxide detector in the spa room contained batteries with a replace date of 12/2016, indicating the batteries had not been replaced in compliance with applicable health and safety laws.”

“Resident #1 sometimes requires three staff members for ADLs and transfers. On 01/26/2024, 01/27/2024, and 01/28/2024, from 11:00pm–7:00am, only three staff members were present with 23 residents in the home, insufficient to safely assist all residents in case of emergency evacuation. This is a repeat violation from 01/05/2023.”

“Residents #2, #3, and #4 each had enabler bars on their beds that were not fastened to the bedframe and were held in place only by the weight of the mattress.”

“Tweezers were missing from the First Aid kit located in the closet behind the nurse's station.”

“Residents #3 and #4 do not have operable lighting available to them at bedside.”

“The refrigerator in the kitchenette had a saucepan with unknown food that was not labeled or dated.”

“The locked door to enter the home from the outside patio space did not have instructions of use posted with the keypad.”

“Resident #5's case record did not include hair color, eye color, or identifying marks as required.”

“A resident wandered into another resident's room, leading to a resident-to-resident altercation where one resident punched another in the face. Both residents were sent to the emergency room for medical evaluation.”

“A resident's RASP (support plan) was not updated to reflect the resident's psychiatric hospital stay and psychiatric evaluation following increased agitation and resident-to-resident altercations.”