Unger Park Post Acute

Inspectors wroteBased on review of the medical record, review of the beneficiary notification documentation, staff interview, and policy review, the facility failed to ensure residents were provided the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This affected four (#2, #41, #76, and #77) of four residents reviewed for required beneficiary notices. The facility census was 67.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure the kitchen was sanitary, failed to ensure food was labeled and dated when opened, and further failed to ensure the dishwasher was washing and rinsing per manufacturer guidelines. This had the potential to affect all residents who received food from the kitchen. The facility identified one (#72) resident who did not receive meals from the kitchen. The facility census was 67.

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure staff wore personal protective equipment during high contact resident care for residents requiring enhanced barrier precautions. This affected three (#23, #72, #75) of four residents reviewed for enhanced barrier precautions and had the potential to affect nine residents (#4, #9, #11, #14, #18, #23, #28, #72, and #75) on enhanced barrier precautions. Additionally, the facility failed to ensure hand hygiene during wound care was completed. This affected one (#28) of one resident reviewed for wound care. The facility identified five residents requiring wound care. The facility census was 67.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure the facility was maintained in a safe, clean, comfortable homelike environment. This affected two residents (#46 and #56) and had the potential to affect all residents. The facility census was 67.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure female residents were shaved. This affected one (#75) of one resident reviewed for shaving. The facility also failed to ensure residents in the dining room were fed in a dignified manner. This affected one (#45) of one resident observed for feeding. The facility identified seven residents (#6, #12, #27, #45, #60, #66, and #74) who required assistance with feeding. The facility census was 67.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to obtain informed consent before treatment with psychotropic medications. This affected one (#26) of five residents reviewed for psychotropic medications and has the potential to affect 31 (#2, #5, #7, #12, #13, #14, #17, #19, #20, #21, #22, #23, #32, #33, #34, #35, #39, #40, #42, #43, #45, #46, #47, #49, #51, #55, #56, #59, #60, #62, and #75) residents that the facility identified as receiving psychotropic medications. The facility census was 67.

Inspectors wroteBased on observation, review of the medical record, staff interview, review of the Resident Council meeting minutes, review of the concern/grievance log, and policy review, the facility failed to ensure timely response and follow-up of resident concerns. This affected one (#3) of two residents reviewed for personal property. The facility census was 67.

Inspectors wroteBased on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure a homelike environment by failing to ensure the dining room ceiling was intact and without holes. This affected one (#28) of five residents reviewed for environment. The facility also failed to ensure a homelike dining experience for the 14 (#2, #3, #5, #14, #16, #17, #20, #28, #43, #45, #52, #53, #56, and #59) residents who routinely ate meals in the dining room and further failed to provide comfortable and well-fitting bed linens for Resident #10. The facility census was 67.

Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to ensure adequate adverse effect monitoring for a resident using psychotropic medications. This affected one (#26) of five residents reviewed for unnecessary and psychotropic medications. The facility census was 67.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure bed hold notices and transfer notices were given to residents. This affected one (#68) of one resident reviewed for bed hold notices and transfer notices. The facility census was 67.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure care plans were timely initiated and revised for new wounds. This affected one (#28) of one resident reviewed for wound care. The facility identified five residents with wounds. The facility census was 67.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review the facility failed to ensure a procedure was in place to determine which residents required ancillary services. This affected one (#51) of one resident reviewed for dental services. The facility census was 67.

Inspectors wroteBased on staff interview, review of employee files, review of the Bureau of Criminal Investigation (BCI) log and review of the facility policy, the facility failed to ensure employee background checks were completed prior to employment. This had the potential to affect all 56 residents residing in the facility. The facility census was 56.

Inspectors wroteBased on medical record reviews, staff interviews, review of the facility's infection control logs, review of facility in-services, and review of the facility's policy, the facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs). This affected two (#16 and #60) of two residents reviewed for UTIs. The facility census was 74.

Inspectors wroteBased on interviews, record review, policy review, the facility failed to ensure care conferences were completed timely. This affected six residents (#05, #07, #08, #12, #19, #29, and #45) of the 19 residents reviewed for care conferences. The facility census was 74.

Inspectors wroteBased on observation, record review, staff interview, review of the activity calendar, and policy review the facility failed to ensure activities on memory care unit met the needs and preferences of the residents. This affected all 13 residents (#02, #04, #11, #13, #19, #24, #35, #40, #41, #46, #58, #174, and #175) on the memory care unit. The facility census was 74.

Inspectors wroteBased on medical record review, review of physician and nurse practitioner (NP) progress notes, and staff interview, the facility failed to ensure physician visits were completed as required. This affected five (#60, #04, #12, #29, and #45) of the nine residents reviewed for physician visits. The facility census was 74.

Inspectors wroteBased on observation, resident interviews, staff interviews, and policy review, the facility failed to ensure residents received food that was palatable and appetizing to them and which met their nutritional recommendations. This affected four (#57, #05, #62 and #61) residents out of the four residents reviewed for lunch. This had the potential to affect all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This affected all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74. Findings Include: Observation of the kitchen on 12/16/24 at 10:59 A.M. with Dietary Manager (DM) #333, revealed the wall across from dishwasher had splattered food debris all over it and parts of the wall were chipping. Interview with DM #333 at the same time, verified the findings. Observation of the kitchen on 12/16/24 at 11:20 A.M. with DM #333, revealed the ventilation hood above the clean pan rack and stove top has paint strips hanging down from it. DM #333 verified the findings and stated someone cleaned too hard and now paint is hanging down. Follow up observation of the kitchen on 12/18/24 at 11:14 A.M. [...]

Inspectors wroteBased on observation, staff interviews, record review, and policy review the facility failed to ensure the kitchens walk-in cooler and reach-in cooler were working in a safe operable condition. This had the potential to affect all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the code status matched the medical record and the physician's order. This affected one (#12) of the 19 residents reviewed for code status. The facility census was 74.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility policy, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment. This affected one (#37) of two residents reviewed for physical environment. The facility census was 74.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to administer tube feedings in accordance with physician orders. This affected one (#130) of the one resident reviewed for administration of tube feedings. The facility census was 74.

Inspectors wroteBased on record review, and staff interview, the facility failed to provide medications as ordered by the physician which resulted in significant medication errors. This affected one (#29) of one resident reviewed for insulin. The facility census was 74.

Inspectors wroteBased on employee personnel records, background check log, and staff interviews, the facility failed to ensure reference checks were completed for four new employees. This affected four (Registered Nurse [RN] #229, Social Worker/Administrative Assistant [SW/AA] #869, Medication Technician [MT] #388, and Certified Nursing Assistant [CNA] #443) of the four personnel files reviewed but had the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on medical record review, staff interview, review of Self Reported Incidents (SRI), review of facility investigations, review of the local police report, and review of policies and procedures, the facility failed to prevent an inappropriate resident to resident altercation that was sexual in nature. This affected one resident (#105) out of three residents reviewed for abuse. Findings Include: Review of the medical record for Resident #105 revealed an admission date of 11/21/24. The resident was discharged on 11/25/24. Diagnoses included hemiplegia and hemiparesis following other cerebrovascular disease affecting the right dominant side, cerebrovascular disease, dysphagia following cerebral infarction, and type two diabetes mellitus with chronic kidney disease. The resident was only admitted for a short term respite stay. [...]

Inspectors wroteBased on observation, record review, staff interview, and facility policy review the facility failed to ensure medications were fully ingested and not left at the bedside. This affected one resident (#21) and had the potential to affect eight residents (#65, #20, #45, #6, #31, #68, #57, and #60) the facility identified as independently mobile and cognitively impaired residing on the memory care unit. The facility census was 68.

Inspectors wroteBased on observations, staff interview, record review, policy review, and staff interview, the facility failed to ensure dishes and utensils were sanitized properly. This had the potential to affect 64 residents that received meals from the facility. One resident (#1) of 65 residents received nothing by mouth. The census was 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were offered the COVID-19 vaccination/booster and provided education on vaccinations. This affected three (#8, #15, and #69) of five reviewed for vaccination. Additionally, the facility failed to have a policy and procedure related to residents receiving the COVID-19 Vaccination, which affected all facility residents. Findings census was 65.

Inspectors wrote2. Review of Resident #8's medical record revealed an admission date of 08/24/21, with diagnoses of stroke, schizophrenia, major depression and anemia. Review of Resident #8's activities plan of care identified she enjoys cards, games (rummy and Bingo) art/crafts, coloring, computer/tablet games, cooking, country music, religious involvement, travel, outings, movies, parties and socials events. The plan identified she needs assistance to and from activities. Observations on 02/12/24 at 7:41 P.M. and 02/13/23 at 11:25 A.M., revealed Resident #8 was awake and staring at the television in the room. Resident #8's room was observed to have no independent items in the room to do activities. The room had no games, coloring books and or radio to enjoy her identified preferred activities. Review of the facility's activity calendar dated 02/13/24 identified at 2:00 P.M., for a Mardi gras party. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This potentially affected nine residents, eight who were prescribed puree diets (#8, #12, #28, #40, #44, #58, #65 and #224) and one resident (#59) who was prescribed meat must be pureed. The census was 65.

Inspectors wroteBased on medical record review, Centers for Disease Control Prevention (CDC) guideline review, policy review and staff interview, the facility failed to ensure residents were offered vaccinations and provided education on vaccinations. This affected two (#8 and #15) for influenza (flu) vaccines and one (#13) for pneumococcal (pneumonia) vaccines of five residents reviewed for vaccines. Findings census was 65.

Inspectors wroteBased on record review, policy review, resident interview, and staff interview, facility failed to ensure resident and/or a representative and members of the interdisciplinary team were included in the quarterly care conferences. This affected one (#13) of two residents reviewed for care conferences. Facility census was 65.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to ensure call lights were within reach and accessible for two (#12 and #34) residents. In addition, the facility failed to ensure a resident (#6) was provided the opportunity to smoke or the necessary interventions to cease smoking. This affected three (#6, #12 and #34) of 65 residents reviewed for accomodation of needs. The facility census was 65.

Inspectors wroteBased on medical record reviews, review of a facility self reported incident (SRI), resident and staff interviews, the facility failed to promote and facilitate a resident to have visitors of their choosing and where they want to meet. This affected one (#8) of 18 sampled for residents rights. The facility census was 65.

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to ensure residents had an accurate code status documented in the medical record. This affected one (#5) of two reviewed for advanced directives. Facility census was 65.

Inspectors wroteBased on medical record review, review of the Resident Assessment Instrument (RAI) manual and staff interview, the facility failed to ensure the Minimum Data Sets (MDS) and fall risk assessments were completed accurately. This affected three (#8, #29, #68) of 18 sampled residents assessments reviewed. The facility census was 65.

Inspectors wroteBased on record review and staff interview, facility failed to ensure pre-admission screening and resident review (PASARR) were completed accurately and corrected as needed. This affected two (#7 and #13) of two residents reviewed for PASARR. Facility census was 65.

Inspectors wroteBased on record review and staff interview, the facility failed to update care plans regarding elopement and advanced directives. This affected one (#25) of 18 sampled residents care plans reviewed. The facility census was 65.

Inspectors wroteBased on observations, medical record reviews, resident and staff interviews, the facility failed to ensure a resident was provided the necessary glasses to maintain vision. In addition, ensure a system was in place for staff to identify which resident requires assistive devices. This affected one (#8) of 18 sampled residents. The facility census was 65.

Inspectors wroteBased on observations, record reviews, policy reviews, and staff interviews, the facility failed to ensure a resident was accurately assessed after an elopement attempted, ensure staff was informed to monitor resident after an elopement attempt, and a resident's fall interventions were implemented. This affected two (#15 and #46) of two residents reviewed for accidents and hazards. Facility census was 65.

Inspectors wroteBased on observations, medical record reviews, dietary meal cards review, and staff interviews, the facility failed to ensure a physician ordered fluids restriction was being provided as ordered. This affected one (#40) of one resident identified with fluid restriction. The facility census was 65.

Inspectors wroteBased on medical record review, policy review, fire department run sheet review, resident and staff interviews, the facility failed to document accurate pertinent changes that occurred in Resident #69 condition. This affected one (#69) of 18 sampled residents. The facility census is 65.

Inspectors wroteBased on record review, policy review, self reported incident review, and staff interview, the facility failed to ensure a complete and thorough investigation was completed into an allegation of physical abuse alleged. In addition the facility failed ot provide protection for residents agianst the alleged abuser. This had the potential to affect all 65 residents in the facility. The facility census was 65.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the correct posted staffing was completed daily. This had the potential to affect all 65 residents. The facility census was 65.