Union Post Acute

Based on observation, interview, and facility policy review, the facility failed to store foods in accordance with professional food storage standards for labeling and dating for 1 of 1 resident refrigerator observed. Findings included: A facility policy titled, Food Receiving and Storage, revised November 2022, revealed, Refrigerated/ Frozen Storage. 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated ('use by' date). The policy revealed, 7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded. The policy revealed the section titled Foods and Snacks Kept on Nursing Units indicated, 2. All foods belonging to residents are labeled with the resident's name, the item and the 'use by' date. A tour of the facility D-Wing Nursing Station was conducted with the Dietary Director (DD) on 01/15/2025 at 6:37 AM, revealed the following unlabeled, undated food items, were observed in the refrigerator designated for residents' food: - Two transparent, plastic bowl containers of beef stew. - One…

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 facility policy review, the facility failed to ensure 1 (Resident (R)16) of 19 sampled residents was assessed to determine whether the resident could safely self-administer medications prior to keeping the medication at the resident's bedside. Findings included: A facility policy titled, Self-Administration of Medications, revised February 2021, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy revealed, 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy revealed, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. An admission Record revealed the facility admitted R16 on 08/29/2023. According to 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, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to address contractures, which affected 1 (R29) of 1 resident reviewed for limited range of motion (ROM) concerns. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated, 7. The comprehensive, person-centered care plan: included b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment and (3) which professional services are responsible for each element of care. The policy revealed the comprehensive, person-centered care plan also e. reflects currently recognized standards of practice for problem areas and conditions. A facility policy titled, Resident Mobility and Range of Motion, revised…

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, record review, and facility policy review, the facility failed to ensure a quarterly care plan meeting was held for 1 (Resident (R)37) of 19 sampled residents. Findings included: A facility policy titled, Care Planning- Interdisciplinary Team, revised 03/2022, indicated, 1. Resident care plans are developed according to the timeframes and criteria established by §483.21 [public health code of federal regulations for comprehensive person-centered care planning] The policy revealed, 5. Care Plan meetings are scheduled at the best time of the day for the resident and family when possible. An admission Record revealed the facility admitted R37 on 06/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of myotonic muscular dystrophy, unspecified anxiety disorder, unspecified depression, chronic congestive heart failure, and presence of a cardia pacemaker and automatic cardiac defibrillator. R37's IDT [Interdisciplinary Team] Conference Notes, dated 07/11/2024, revealed an admission conference was held. According to 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, record review, and facility policy review, the facility failed to provide interventions to prevent the development or worsening of contractures for 1 (Resident (R)29) of 1 resident reviewed for limited range of motion concerns. Findings included: A facility policy titled, Resident Mobility and Range of Motion, revised 07/2017, indicated, 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. An admission Record revealed the facility admitted R29 on 05/08/2019. According to the admission Record, R29 had a medical history that included a diagnosis of unspecified Alzheimer's disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R29 had severe impairment in cognitive skills 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.

Based on interview, record review, and facility policy review, the facility failed to accurately monitor and document the amount of fluid consumed by a resident with a physician ordered fluid restriction. The deficiency affected 1 (Resident (R)62) of 2 residents reviewed for nutrition. Findings included: A facility policy titled, Resident Hydration and Prevention of Dehydration, revised 10/2017, indicated, 3. Physician orders to limit fluids will take priority over calculated fluid needs. The policy revealed, Fluid restrictions will be assessed by RD [Registered Dietician] and orders to include breakdown by dept [department] and shift. The policy revealed, 12. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. An admission Record revealed the facility admitted R62 on 12/12/2023. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease, dependence on renal dialysis, kidney transplant status, and unspecified systolic congestive heart failure. An annual Minimum Data Set (MDS),…

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, record review, and facility policy review, the facility failed to provide oxygen therapy in accordance with professional standards of practice and the comprehensive care plan for 2 (Resident (R)37 and R38) of 4 residents reviewed for respiratory care. Specifically, the facility failed to administer R38's supplemental oxygen per physician orders and failed to obtain a physician's order for supplemental oxygen for R37. Findings included: A facility policy titled, Oxygen Administration, revised 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 1. An admission Record indicated the facility admitted R38 on 12/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). An admission Minimum Data Set (MDS), 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.

Based on interview, record review, and facility policy review, the facility failed to ensure the attending physician documented a clinical rational when declining pharmacy recommendations, which affected 1 (Resident (R)29) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Antipsychotic Medication Use, revised 07/2022, indicated, Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject gradual dose reduction and re-review. The policy revealed, 9. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) behavioral interventions have been attempted and included in the plan of care, except 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 observation, interview, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5 percent. Observation of medication administration revealed staff made two errors during 27 medication opportunities, resulting in a medication error rate of 7.41 percent. Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy revealed, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An admission Record revealed the facility admitted R3 on 01/26/2018. According to the admission Record, the resident's medical history included an unspecified vitamin D deficiency and chronic idiopathic constipation. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/2024, revealed R3 had 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.

Based on observation, interview, and record review, the facility failed to maintain and store oxygen equipment in a manner to prevent the development or spread of infection for 1 (Resident (R)37) of 4 residents reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, revised 10/2010, revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy did not address storage or changing oxygen tubing. On 01/17/2025 at 5:53 PM, the Regional Director of Clinical Services (RDCS) revealed the facility had no policy for the storage of oxygen tubing. The Director of Nursing (DON) was interviewed on 01/17/2025 at 3:32 PM. The DON stated oxygen tubing should be stored in a bag when not in use to decrease contamination. The DON stated third shift staff should change oxygen tubing weekly. An admission Record revealed the facility admitted R37 on 06/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of myotonic muscular dystrophy, unspecified anxiety disorder,…

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, record review, and facility policy review, the facility failed to report an allegation of sexual abuse to the state agency that involved 1 (Resident (R)2) of 4 sampled residents reviewed for abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy specified, 3.…

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, staff interviews, and record review, the facility failed to ensure food stored in the main kitchen was labeled, dated, and had not expired. Additionally, staff failed to utilize safe food handling. The failures had the potential to increase the prevalence, spread of foodborne illness, and cross contamination for all 82 residents residing in the facility. Findings include: Review of the facility's policy titled Food and Nutrition Services dated 07/2018 documented, Foods are labeled for food safety. Information on the label tells staff when food is approaching dates when it would be removed from service. On 05/08/23 from 8:49 AM to 9:25 AM, the following items were observed during the initial kitchen tour: -A dirty and rusted-looking can opener. -The countertop next to the sink with food debris, and underneath the sink noted stained floor. -Pantry with non-labeled and non-dated bag of pasta, grits, cornbread mix and angel food cake. An interview on 05/08/23 at 9:10 AM with the Dietary Manager (DM), acknowledged the can opener was dirty and rusted. DM stated that…

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, record review, and interviews, the facility failed to ensure one Resident (R)12 reviewed for behavior management received the appropriate behavioral health care and management to attain her highest practicable well-being. Findings include: Review of the facility's policy titled Psychotropic Medication Use dated 08/2018, documented, Medication dose adjustments are periodically considered based on person centered factors. During an observation conducted on 05/09/23 at 5:00 PM, R12 was observed beside her bed, seated in her wheelchair, and noted with hand tremors. R12 acknowledged she could not calm down when she was anxious, and she had to ask for her Ativan medication. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/23, located in the electronic medical record (EMR), under the MDS tab, indicated R12 was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and Parkinson's disease. Review of R12's Plan of Care dated 05/18/23,…

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.