Unity Healthcare And Rehabilitation Center

Based on interview and record review, the facility failed to implement their policy and procedures on abuse for one (Resident #1) out of one sampled resident whose abuse report was reviewed. This facility practice had the potential to have a negative impact on the health and safety of all 263 residents residing in the facility at the time of the survey. The findings included: Review of the facility's Abuse Reporting Timeline Audit revealed an abuse of unknown injury or fracture occurred on 09/25/2023. Review of Immediate Federal Report revealed the Immediate Report was completed and filed on 09/27/2023 at 8:28 PM while the administrator was notified on 09/25/2023 at 10:30 AM. Interview with the Director of Nursing (DON) on 10/05/2023 at 01:55 PM, the DON confirmed that the initial report was filed about 2 days after the alleged abuse first reported. The DON stated, The procedure is to report the incident right away. I had a case where they sent the resident to the hospital without bruises or redness. After they told me there was a fracture, I did the report. It was a teachable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to follow the resident's approved menu for the Regular diets (Resident #189 and Resident #92). This could affect all residents receiving Regular, consistency diets (145 residents). The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular Diet consistency had 3 ounces of honey-glazed ham,4 ounces of red cabbage, and 4 ounces of seasoned roasted potatoes. The Diet Type Report provided by the facility showed that 145 residents are on a Regular diet consistency. In an observation conducted on 11/15/22 at 1:40 PM, Resident #189 was noted in his room with the lunch tray at his bedside. Closer observation showed a lunch meal that had the following: a slice of glazed ham, purple cabbage, and roasted potatoes. In this observation, Resident #189 stated that the ham is so small that he is not sure that it weighs 3 ounces. A chart review showed that Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure resident's rooms are designed and equipped for adequate nursing care, comfort, and privacy of residents in a safe manner. Semi-private resident rooms measured under the required 80 square feet per resident and multiple residents complained to the surveyors of their rooms being cramped and cluttered. The findings included: Review of a Memo provided to the surveyors by the facility's Administrator revealed the following: 81 rooms in the facility are semi-private rooms. Of these, 58 measure 157 square feet-which equates to less than the required 80 square feet per resident. These measurements do not include the bathroom or closet storage space in the rooms. During a tour of the facility conducted on 11/16/22 at 11:00 AM, it was noted by the surveyors that a number of the facility's semi-private rooms appeared to be small. It was noted in room [ROOM NUMBER] that a wheelchair between the beds was touching the side rails of each bed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide the correct food consistencies for the Mechanical Soft Diets for 2 of 2 residents during dining observations (Resident #10 and Resident #167). This has the potential to affect 38 residents on the Mechanical Soft diet. The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular diet consistency had honey-glazed ham, red cabbage, and seasoned roasted potatoes. The Mechanical soft diet had ground honey-glazed ham, red cabbage, and mashed potatoes. The Diet Type Report provided by the facility showed that 38 residents are on a Mechanical soft consistency diet. In an observation conducted on 11/15/22 at 8:45 AM, Resident #10 was noted in the room with her breakfast tray in front of her. Closer observation showed a breakfast meal with a large piece of bread approximately 3 inches long that was untoasted and hard to the touch. It also had a ground sausage patty and scrambled eggs. The meal ticket on the tray showed that Resident #10 was on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist with resident's right to vote for 1 of 1 sampled residents (Resident #225). The findings included: Record review revealed Resident #225 was admitted to the facility on [DATE]. A comprehensive assessment, dated 10/15/22, documented the resident was cognitively intact, and required extensive one-person assist with activities of daily living. An interview was conducted with Resident #225 on 11/15/22 at 12:00 PM. Resident #225 stated he had been trying to get in touch with social services for approximately two months in order to assist in voting. Resident #225 further stated he was not able to vote this past election. Resident #225 stated he was very upset, as he has not ever not voted. Resident #225 stated this needed to be fixed so as it does not happen again. A subsequent interview was conducted with Resident #225 on 11/17/22 at 9:00 AM. Resident #225 stated he had called the receptionist at the front desk several times to request…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and policy review, the facility failed to provide showers per resident request for 1 of 251 sampled residents screened in the initial pool (Resident #121). The findings included: The facility's policy titled Standards and Guidelines: SG Showers/Bathing issued 03/08/10 and revised 03/27/21 revealed It will be the standard of this facility to assure that showers/bathing are offered to residents at least 2 times weekly or per resident/representative preference unless specifically ordered otherwise by the physician or care planned otherwise. Refusals for showers/bathing should be reported to the licensed nursing staff . On 11/15/22 at 11:29 AM, Resident #121 was interviewed during the initial screening process. Resident #121 was observed in a hospital type gown, lying in bed. The resident stated that he would like to get dressed when he got out of bed. He also stated that he never got a shower. He was given a bed bath but would like a shower ideally everyday. Resident #121 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 9 out of 36 sampled residents (Residents #11, #27, #63, #105, #129, #146, #203, #255, #459). Review of the facility's policy titled Work Orders, Maintenance with no date included the following: To establish priority of maintenance service, work orders must be filled out electronically using an online application such as TELS and forward to the Maintenance Director. It shall be the responsibility of the department directors and employees to fill out and submit work orders to the Maintenance Director. Work orders are reviewed daily. Emergency or critical work orders would be called in to the Maintenance Director. Emergency requests will be given priority. On 11/15/22 at 9:54 AM an observation of vent with missing slats coated with dust across from the shower room near the 2 South Nursing Station. On 11/15/22 at 10:15 AM an observation was made in Resident # 203's room of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to provide fingernail grooming (Resident #10 and Resident #94) to assist with dining (Resident #94) and failed to provide care and services to prevent a decline in the range of motion (Resident #117, Resident #231, and Resident #225) for 5 of 5 sampled residents for Activities of Daily Livings (ADLs). The findings included: A review of the facility's policy titled ADL Care and Assistance, revised on 03/27/21, showed that the following: each Resident will be assessed/evaluated upon admission or shortly after for their level of resident ability/function and staff assistance required to perform ADLS safely. The Minimum Data Set (MDS) assessment is an example of an assessment/evaluation of the level of resident ability/function and staff assistance required to perform ADLs. Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the Resident while ensuring the needs and desired goals.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess for safety of smoking for 1 of 2 sampled residents (Resident #217). The findings included: A review of the facility's policy Safe Smoking, dated 10/01/2004, and revised 03/27/21, documented: Electronic vapor cigarettes will be addressed and accommodated per the same guidelines as for actual cigarettes. A safe Smoking Screen is performed on admission for a resident who wishes to smoke. Resident #217 was admitted to the facility on [DATE]. An admission comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required limited to extensive one to two-person assist with activities of daily living. The assessment further documented the resident did not use tobacco. Record review revealed a care plan dated 11/15/22, documented Resident #217 desires to smoke. Resident has been assessed as able to smoke independently. A review of a Smoking Evaluation form dated 11/14/22 revealed the document was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to assess for removal of indwelling urinary catheter when clinical condition demonstrates that catheterization is not necessary for 1 of 2 sampled resident for indwelling urinary catheter (Resident #212 and #194). The findings included: Review of the facility's policy titled, Standards and Guidelines: SG (Standards and Guidelines) Indwelling Catheters, with a revised date of 03/27/21, included the following: It will be the standard of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Under Guidelines included: 1. Indication for Indwelling Catheter use: Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible. Contamination of Stage III or IV pressure ulcers (or greater) with urine which has impeded healing. Terminal illness or severe impairment, which makes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to provide nutritional assessments in a timely manner and failed to ensure the accuracy of admission/monthly weights for 4 of 8 residents reviewed for nutrition (Resident #94, Resident #40, Resident #128, and Resident #54). The findings included: 1. In an observation conducted on 11/15/22 at 1:07 PM, the lunch tray arrived for Resident #94 and was placed on her side table. Staff left the tray at the bedside and walked out to help pass other lunch trays. At 1:15 PM, Resident #94's tray was about 5% consumed, and no staff was noted in the room assisting her with the lunch meal. Continued observation at 1:29 PM showed that Resident #94's tray was left 95% untouched. In an observation conducted on 11/16/22 at 9:40 AM, Resident #94 was noted in her room with the breakfast tray in front of her. She was observed eating one tablespoon of the eggs, but everything else on the tray was untouched. The closer observation did not show any staff in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations and interviews, the facility failed to provide proper tracheostomy care for 1 of 1 resident reviewed for tracheostomy care, Resident #212. The findings included: Review of the facility's written procedure titled Trach Care Competency Check List, undated, revealed the following: Apply sterile gloves. The dominant hand will remain sterile. With non-dominant hand, remove oxygen source. Then unlock and remove inner cannula. Place tracheostomy collar over outer cannula. Quickly clean the inside and outside of the inner cannula with brush. With sterile gloved hand, replace inner cannula and lock in place. Replace tracheostomy collar. Observation of tracheostomy care on 11/18/22 at 10:10 AM for Resident #212. The surveyor obtained consent from the resident prior to the start of tracheostomy care. The staff members involved in Resident #212's tracheostomy care were Staff L, Respiratory Therapist, Staff M, Respiratory Therapist, and Staff N, Respiratory Nurse. The surveyor asked Staff L who normally performs tracheostomy care and respiratory medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow infection control guidelines as per Centers for Disease Control and Prevention (CDC) recommendations during the disconnection of dialysis treatment for 1 of 1 Resident Observed during dialysis (Resident #8). The findings included: A review of the Centers for Disease Control and Prevention (CDC) recommendations, titled Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, Showed the following: Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews, the facility failed to secure unattended medications in the medication refrigerator for 1 out of 8 nursing stations, the facility failed to properly secure medication and treatment carts for 2 out of 16 carts, the facility failed to ensure proper disposal of medications during 1 medication administration observation. The findings included: Review of the facility's policy titled Standards and Guidelines: Medication Storage, revised 10/24/22, revealed the following: The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals. Compartments containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view. Medications will be destroyed following FDA, State and Local requirements. Review of the facility's policy titled Standards and Guidelines: Medication Documentation, revised 03/03/21, revealed the following:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to honor the residents food preferences, and food intolerances for 3 of 3 residents reviewed for foods (Resident #189, Resident #192, and Resident #100). The findings included: In an observation conducted on 11/15/22 at 9:00 AM, Resident #189 was in the room when his breakfast tray arrived. The tray was noted with over easy-cooked eggs, sausage patty, and a large piece of bread approximately 3 inches long. Closer observation showed a Regular carton of 2% milk and 8 ounces of juice. The meal ticket on the tray showed that Resident #189 was lactose intolerant and liked Sunnyside-up eggs. In this observation, Resident #189 stated that he did not like how they cooked his eggs and wanted his eggs sunny side up. He pointed to the Regular milk and said that he was lactose intolerant and that they always make a mistake and bring him Regular milk. He then picked up the large piece of bread on his tray and said, see, it is hard as a rock. In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety, which included: failure to maintain sanitary conditions in the main kitchen, failure to date and label all food items, and failure to dispose of expired foods, in the central kitchen. The findings included: In a tour conducted on 11/15/22 at 8:30 AM in the main kitchen, the following was noted: In the dry storage area, 12 bottles that were 46 ounces each of Cranberry juice had a used-by date of 08/16/22, which expired over three months (photographic evidence obtained). In the dry storage area, five large, dented cans were 6.56 pounds each (photographic evidence obtained). The dry storage area's floor was noted with debris and dirt. One large garbage can was pointed out with the lid wholly opened and empty food boxes near it (photographic evidence obtained). A large Thickener bin was noted with the scoop inside (photographic evidence obtained). The food production area was noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to maintain a medical record that is complete and accurate for 1 out of 2 sampled residents with an indwelling urinary catheter. (Resident #212). The findings included: Review of the facility's policy titled, Standards and Guidelines: SG (Standards and Guidelines) Indwelling Catheters, with a revised date of 03/27/21, included the following: It will be the standard of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Under Guidelines included: 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site. 13. Pertinent information regarding care and changes in condition related to the indwelling catheter should be documented in the clinical record. 14. Use of the indwelling catheter should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure an effective call light system for 2 South (24 rooms). The findings included: On 11/15/22 at 11:40 AM this surveyor entered the room of Resident #244. The resident stated that she felt wet and needed to be changed. At 11:47 AM this surveyor asked her to press her call light so staff will be aware of her needs. At 11:54 AM no staff had come yet to answer the light. This surveyor looked out in the hallway and the light above the door to the room was on. This surveyor then walked to the nurse's desk where Staff H, a Licensed Practical Nurse (LPN) was present at the desk. She was asked if she realized that a call light was on and she stated that she did not hear it ringing so the call light in that room must not be working. She then notified the Director of Maintenance. On 11/15/22 at 1:30 PM another surveyor went into room [ROOM NUMBER] and room [ROOM NUMBER] and pressed the call lights. Observed Staff H at the desk with the call bell system behind…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to equip corridors with firmly secured an unbroken handrail. The findings included: Review of the facility's policy titled Work Orders, Maintenance with no date included the following: To establish priority of maintenance service, work orders must be filled out electronically using an online application such as TELS and forward to the Maintenance Director. On 11/15/22 at 1:25 PM an observation of a loose handrail next to room [ROOM NUMBER]. On 11/15/22 at 10:20 AM an observation was made on the second floor across from the elevator of corner handrail broken with sharp edges exposed. On 11/15/22 at 10:20 AM an observation was made on the first floor across from the elevator of corner handrail broken with sharp edges exposed. During a tour of the facility conducted on 11/18/22 at 9:00 AM with the Director of Maintenance he stated that some of the issues identified, he was not aware of. During an interview conducted on 11/18/22 at 9:45 AM with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.