Unity Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews conducted during an Abbreviated Survey (NY00352620), the facility did not ensure resident records were complete, accurately documented, accessible, and systematically organized in accordance with professional standards of practice for three (3) (Residents #1, #2 and #4) of three (3) residents reviewed. Specifically, the facility could not provide documented evidence that wound treatments were administered as ordered, and documentation did not include who provided the treatments or when the treatments were completed. The findings include: The facility's policy Skin Inspection and Care, dated June 2024, documented that nursing staff were to perform and document weekly skin assessments for each resident. Nursing staff were to document changes in wound condition and new wounds under a lines, drains, and airways avatar as well as in a skin assessment flowsheet within the electronic medical record and were responsible for adding wound care to the daily work list in the electronic…

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 interviews, observations, and record reviews conducted during a Recertification Survey from 7/19/24-7/25/24, for two (Residents #20 and #93) of three residents reviewed for medication administration, the facility did not ensure that each resident was free from significant medication errors. Specifically, several significant medications were not administered to both Resident #20 and Resident #93 due to not being available. This is evidenced by the following: The facility's policy Medication Administration dated August 2021, documented the facility shall properly administer and store all medications. Medications are administered following a valid order entered in the Electronic Medical Record which links to the Medication Administration Record. 1. Resident #20 had diagnoses that included chronic obstructive pulmonary disease, seizure disorder, and hypertension (high blood pressure). Resident #20's current physician orders included Lasix (diuretic or water pill) 20 milligrams once daily and Topamax (anti-seizure medication) 250 milligrams every 12 hours. Review of the July…

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 conducted during the Recertification Survey from 7/19/24-7/25/24, for one of four residential units (3300 unit), the facility did not provide for safe and secured medications in accordance with currently accepted professional standards. Specially, there were multiple loose unpackaged and unlabeled pills and expired medications observed in two medication carts on the 3300 Unit. The Medication Administration Policy, dated February 2020, included that the facility shall properly store all medications. All medications must remain in secure storage until administered to the patient. During an observation and interview on 7/22/24 at 12:22 PM on the 3300 resident care unit, the team one hall medication cart contained 25 loose unlabeled pills (different shapes and colors) in the medication drawers. Licensed Practical Nurse #1 stated they thought some of the pills were senna (stool softener) but was unable to identify any of the other loose pills. Licensed Practical Nurse #1 stated they did not know who was responsible for cleaning 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 observations, interviews and record review conducted during a Recertification Survey, completed on 9/9/22, it was determined that for 3 of 29 residents reviewed for care planning, the facility did not develop and implement a comprehensive person- centered care plan that included measurable objectives to meet all the resident's medical, nursing, mental and psychological needs as identified in their comprehensive assessments. Specifically, Resident #18's Comprehensive Care Plan (CCP) did not include goals, interventions and desired outcomes related to dementia with behaviors, depression or that the resident had a seizure disorder. Resident # 81's CCP did not address nutrition and hydration needs related to end stage renal disease (ESRD) requiring hemodialysis, and Resident #94's CCP did not include goals and interventions related to visitors providing personal care for the resident who was on transmission-based precautions for multiple infections. This was evidenced by the following: 1. Resident #18 had diagnoses that included vascular dementia with behavioral disturbances,…

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 reviews conducting during the Recertification Survey from 8/31/22 to 9/9/22, it was determined that for one (Resident #81) of five residents reviewed for nutrition, the facility did not ensure that the resident's daily fluid intake met their needs as ordered by the physician. Specifically, the physician ordered fluid restriction was not being consistently monitored or documented. This is evidenced by the following: The facility policy, Encouraging or Restricting Fluids, dated 10/28/19, instructed staff to verify if there was a physician's order for this and to review the resident's care plan and/or the daily assignment sheet to assess for any special needs. The General Guidelines included: To follow specific instructions concerning fluid intake or restrictions concerning fluid intake. Record fluid intake accurately. Record fluid intake in cubic centimeters (cc). Encourage the resident to follow specific instructions. Maintain intake and output in the resident's…

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 conducted during the Recertification Survey, completed 9/9/22 it was determined that for one (Resident #13) of three residents observed during medication pass, the facility did not ensure that it was free of medication error rate of 5 percent (%) or greater. There were 4 medication errors for 28 opportunities resulting in a 14.3 % medication error rate. The issue involved administering three medications at the wrong time and not administering one medication that the nurse signed out as administered. This is evidenced by the following: Resident #13 had diagnoses including type 2 diabetes, hypertension, and gastric ulcer. The Minimum Data Set Assessment, dated 5/16/22, documented that the resident had moderate impairment of cognitive function. Current physician orders included but not limited to, the following medications: a. Novolog insulin 14 units sq (subcutaneous injection) three times daily before meals and scheduled for 7:30 a.m. b. Toprol-XL 24 hour extended release 25 milligrams (mg) daily for hypertension and scheduled for…

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 conducted during the Recertification Survey from [DATE] to [DATE], it was determined that for one (Resident #94) of 29 residents reviewed the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, the facility did not ensure that visitors of a resident on transmission-based precautions, due to multiple communicable (contagious) infections, practiced appropriate infection control prevention. This was evidenced by the following: The current Centers for Disease Control (CDC) guidelines for Transmission-Based Guidelines includes under Contact Precautions: everyone should use personal protective equipment (PPE) appropriately including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment.…

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 interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident # 93) of one resident reviewed for grievances, the facility did not make prompt efforts to resolve a grievance. Specifically, the resident's Health Care Proxy voiced concerns about staff members that were not investigated in a timely manner. This is evidenced by the following: Resident #93 has diagnosis including anoxic brain injury, heart failure, and has a tracheotomy. The Minimum Data Set Assessment, dated 1/21/20, revealed that the resident's cognitive skills for daily decision making were severely impaired, the resident was non-verbal (absence of spoken words), and dependent on staff for all activities of daily living. When interviewed on 2/19/20 at 11:14 a.m., the resident's Health Care Proxy (HCP) said they had reported to the Nurse Manager and the Social Worker that the resident only cries when Certified Nursing Assistant (CNA) #1 cares for the resident. The HCP said that CNA #2 made an inappropriate remark about the resident's medical diagnoses, which…

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 and record reviews conducted during the Recertification Survey, it was determined that for 4 (Residents #11, #33, #72 and #115) of 14 residents reviewed for Baseline Care Plans, the facility did not have documented evidence that a Baseline Care Plan was developed within 48 hours of admission. This is evidenced by, but not limited, to the following: The facility policy and procedure, Baseline Care Plan Policy for Long Term Care, effective January 2018, revealed that upon admission, the facility will begin the process of developing a Baseline Care Plan which will be completed within 48 hours. 1. Resident #11 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, osteoarthritis, and neurogenic bladder. When interviewed on 2/24/20 at 4:27 p.m., the Administrator stated that they were unable to locate a completed Baseline Care Plan for the resident. 2. Resident #33 was admitted to the facility on [DATE] with diagnoses including end stage renal disease requiring…

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.