Union Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to implement their abuse policy when they failed to complete a thorough investigation for an allegation of sexual abuse for one resident (Resident #1) out of one sampled resident, and did not ensure resident safety, when staff allowed Certified Nurse Aide (CNA) A who was alleged of the sexual abuse to continue to have contact with residents during the investigation. The facility census was 58. 1. Review of the facility's Abuse, Prevention and Prohibition policy, revised 2021, showed staff are directed as follows: -While a facility investigation is underway, steps will be taken to prevent further abuse;-When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcomes of the facility investigation, prosecution or disciplinary action against the employee;-The administrator and/or the Director of Nursing (DON) will relay this…

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 and interview, facility staff failed to contact local law enforcement and failed to report an allegation of sexual abuse for one resident (Resident #1) out of one sampled resident to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe. The facility's census was 58.1. Review of the facility's Abuse, Prevention and Prohibition policy, revised 2021, showed staff are directed as follows: -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology;-The person made aware of allegations of abuse or neglect OR the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement;-The allegation will be reported no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/03/25, showed staff assessed the resident as cognitively…

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 facility staff failed to notify residents the different alternate food options available and failed to provide alternative meals for residents which accommodated the residents' preferences for eight residents (Resident #2, #9, #10, #27, #32, #48, #52, and #54) out of 13 sampled residents. This had the potential to affect all residents. The facility census was 46. 1. Review of the facility's Alternates and Meal Substitutions policy, undated, showed alternates shall be available for all meals for residents who dislike the menu items. For breakfast an alternate shall be available for the entree, and at lunch and dinner, an alternate shall be available for the entree and vegetable. These may be offered in the form of a posted alternate, a selective menu, or an always available menu. Alternate choices must be nutritionally consistent with the item it is replacing. Review of the resident council minutes, dated June 2025 and August 2025, showed the council addressed…

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 interview and record review, facility staff failed to refund resident funds within 30 days of discharge from the facility for 12 discharged residents (Resident #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73). The facility census was 46.1.Review of the facility's-maintained Accounts Receivable Report, dated 08/26/25, showed 12 discharged residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account discharge date #62 $282.00 01/25/25#63 $8,280.00 05/05/25#64 $228.45 07/17/24#65 $534.00 05/16/25#66 $7,015.00 07/09/25#67 $2,090.00 07/07/25#68 $282.00 03/14/25#69 $15,576.00 03/30/25#70 $264.00 07/27/25#71 $252.15 12/24/23#72 $564.00 06/30/25#73 $108.00 06/02/25Total $35,475.60During an interview on 08/27/25 at 2:55 P.M., the corporate Business Office Manager (BOM) said he/she has been serving as the interim BOM for the facility over the past month or so. The corporate BOM said he/she would expect for the Accounts Receivable Report to be reviewed by the BOM monthly. The corporate BOM said he/she would expect for 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, facility staff failed to develop and implement a comprehensive person-centered care plan to reflect the care needs for four residents (Resident #4, #33, #54, and #55) out of 13 sampled residents. The facility census was 46.1. Review of the facility policy Resident Assessment Instrument (RAI) Policy, dated 04/14/25, showed the facility will adhere to all Center for Medicare & Medicaid Services (CMS) regulations which are considered the definitive source in completion of the RAI process. This includes coding the Minimum Data Set (MDS) with accuracy, and the development of the comprehensive care plan.2. Review of Resident #4's admission MDS, a federally mandated assessment, dated 02/26/25, showed staff assessed the resident as follows:-Cognitively intact;-Resident not assessed for mood;-Resident assessed as no behaviors.Review of the resident's Physician Order Sheet (POS) dated August 2025, showed staff are directed to monitor behaviors for 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 observation, interview and record review, the facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (F) or higher upon service to residents who ate in their rooms. The facility census was 46.1. Review of the facility's Assistance with Meals policy, revised July 2017, showed the policy directed staff to hold foods at a temperature of 136 degrees or above until served. Review showed the policy did not contain guidance on food temperatures upon delivery to residents. Review of the facility's resident council meeting minutes showed:-Attendees on 06/10/25 listed cold food as an issue;-Attendees on 07/08/25 listed veggies cold, coffee cold, and raw breakfast meats as issues;-Attendees on 08/12/25 listed cold plates and food as issues. Observation on 08/26/25 at 12:45 P.M., showed a service cart next to the steam table contained a large stack of plates which were being used for the resident's noon meal. Observation showed…

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, facility staff failed to utilize personal protective equipment (PPE) for two (Resident #33, and #55) out of three sampled residents on enhanced barrier precautions (EBP) while performing care. Failed to perform appropriate hand hygiene and glove changes in a manner to prevent or reduce the spread of bacteria and other infection causing organisms during perineal care for two (Resident #29 and #61) out of two sampled residents. The facility census was 46.1. Review of the Facility's Dry/Clean Dressing policy, revised on 09/2013, showed: -Clean bedside stand. Establish a clean field;-Wash and dry hands thoroughly;-Put on clean gloves. Loosen tape and remove soiled dressing;-Pull glove over dressing and discard into plastic biohazard bag;-Wash and dry hands thoroughly;-Put on clean gloves;-Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Cleanse from least contaminated area to the most contaminated area (usually…

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 interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 53. Review of the facility provided policies, showed the records did not contain a policy related to the qualifications for Director of Food and Nutrition Services. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 01/04/24. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 06/19/24 at 8:05 A.M., the DM said he/she had been the DM for about a year, and he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or…

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 observation, interview, and record review, facility staff failed to store medications in a safe manner when staff failed to ensure expired medications and supplies were not stored with current resident medications, and failed to ensure all medications and treatments were labeled in two out of four medication carts. Additionally, staff failed to ensure medications were not lose in one medication cart. The facility census was 52. 1. Review of the facility's Storage of Medications, dated April of 2007, showed drugs and biologicals shall be stored in packaging, containers or other dispensing systems in which they are received. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner. Drug containers that have missing, incomplete, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Drugs shall be stored in…

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, facility staff failed to ensure one resident (Resident #3) out of 18 sampled residents who required continuous oxygen received continuous oxygen as ordered by the physician. Facility staff failed to store oxygen tubing and nebulizer masks in a manner to prevent respiratory infection for two residents (Resident #3 and #52) out of 18 sampled residents. The facility census was 52. 1. Review of the facility's Oxygen Therapy Policy, undated, showed all oxygen and nasal cannula tubing should be stored in a plastic bag, that is attached to oxygen concentrator, or E-tank (portable oxygen tank), when not in use. Review of the facility's Nebulizer Treatment policy, undated, showed staff should store nebulizer cannula and tubing in a plastic bag at bedside, with the resident's name and date the equipment was changed. 2. Review of Resident #'3 Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/17/24, showed staff assessed the resident as…

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 observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens and cross-contamination. Facility staff also failed to serve drinks to residents at meals in a sanitary manner and perform hand hygiene as often as necessary to prevent cross-contamination. The facility census was 52. 1. Review of the facility's Dish and Utensil Handling policy, undated, showed the policy directed staff to air dry dishes, cups and glasses prior to storage. Observations on 04/04/23 at 11:07 A.M., showed Dietary Aide (DA) C removed sanitized insulated plate holders and dome covers from the clean side of mechanical dishwashing station while wet, stacked them together and stored them on a service cart. Observation also showed six insulated plate holders and 12 domes covers stacked together wet on the cart. During an interview on 04/04/23 at 12:24 P.M., the Dietary Manager (DM) said staff should allow dishes to dry before they are stacked and put away. Observations on 04/04/23…

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, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair and clean. The facility census was 52. 1. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. Observation on 4/4/23 at 11:35 A.M. showed room [ROOM NUMBER] with an unpainted dry wall patch approximately two feet in length behind the bed. Observation on 4/4/23 at 3:09 P.M., showed Resident #50's room with gouges on the wall behind the bed. Further observation showed gouge marks and black marks on the wall at the foot of the bed. Observation on 4/5/23 at 10:01 A.M., showed Resident #1's room with food and debris on floor, and gouges on the wall behind the bed. Further observation showed the resident's bedside table, and refrigerator with a thick layer of dust. During an interview on 4/5/23 at 10:01 A.M., Resident #1 said staff don't clean his/her room enough. 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 observation, interview, and record review, facility staff failed to ensure the resident's environment remained free of accident hazards when they failed to properly propel seven residents (Resident #10, #20, #22, #25, #33, #40, and #58) in wheelchairs in a manner to prevent accidents. The facility census was 52. Review of the facility's Wheelchair, Use of policy, undated, showed: -The purpose is to provide mobility for the non-ambulatory residents with safety and comfort; -Encourage and instruct resident in proper guidelines for safely propelling the wheelchair; -Place foot pedals in position and ensure feet are resting on the foot pedals when staff are propelling resident distances. 1. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/10/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 12:41 P.M., showed an unidentified staff member propelled the resident in a wheelchair…

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, facility staff failed to ensure one resident (Resident #33) had an appropriate indication for the use of anti-psychotic medications. Additionally staff failed to provide a 14-day stop date for as needed (PRN) antianxiety medication, for six residents (Residents #5, #33, #34, #37, #50 and #52). The facility census was 52. 1. Review of the facility's Psychotropic Medication Use Policy, dated September 2022, showed: -Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective; -Antipsychotic medications shall generally be used only for the following conditions/diagnosis as documented in the record, consistent with the definition in the Diagnostic and Statistical Manual of Mental Disorder; -The timeframe for PRN psychotropic medications, which are not Antipsychotic medications will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or 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.