Unity Healthcare and Rehabilitation Center

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to provide adequate supervision to prevent elopement for one out of three sampled residents as evidenced by; on 08/21/2025 at 6:22 AM Resident # 5, a newly admitted resident who is cognitively intact, exited the building undetected through the door used for the linen delivery that was left open and eventually exited the facility's grounds through the back gate. There were four residents at risk for elopement residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure medications were stored in accordance with professional standards, as evidenced by unsecured medications observed at the bedside in one out of eight sampled residents. There were 257 residents residing in the facility at the time of the survey.

Inspectors wroteOn [DATE] at 10:48 AM, observation of Percutaneous Endoscopic Gastrostomy (PEG) tube care for Resident #243 performed by Staff M, Registered Nurse (RN). Staff M, Registered Nurse gathered peg tube supplies, knocked on Resident #243's door provided privacy, explained the care that will be provided, provided privacy, washed hands, put on gloves, gown and face mask. Staff A removed the old peg tube dressing dated [DATE] and discarded it in a red biohazard bag, removed soiled gloves and put on a new pair of gloves; cleaned the skin around the peg site three times and discarded the soiled gauzes. Staff A, RN removed soiled gloves, put on a new pair of gloves, and applied new peg tube dressing; Staff A, RN removed the gloves, gown and face mask and discarded them in the red biohazard bag . Review of Resident #243's clinical records revealed the resident was admitted to the facility on [DATE]; [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the essential patient care equipment was in safe operating condition for three out of three residents who used mechanical lifts for transfer (Residents # 25, #464, and #129). The mechanical lift used to transfer the residents who required total assistance from the bed to the chair was not working.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to provide a clean environment and housekeeping services for resident's equipment (Resident #258 and Resident #158). There were 266 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 263) out of one resident MDS assessment that was reviewed at the time of survey. There were 266 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide devices for an accident-free environment for one out of nine sampled residents (Resident#32). There were 266 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, records reviewed, and interviews. The facility failed to obtain physician's orders for oxygen treatment for Resident #211. This practice could affect 266 residents who were residing at the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview the facility failed ensure accuracy in the reconciliation in the accounting of all controlled substances for 2 out of 2 residents whose narcotic records were reviewed (Resident#150 and Resident#76). There were 262 residents residing in the facility at the time of survey.

Inspectors wroteBased on record review and interview and the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F584 Safe, Clean, Comfortable, Homelike Environment, F689 Free of Accident Hazards, Supervision, Devices, F695 Respiratory/Tracheotomy Care and Suctioning. These repeated deficiencies have the potential to affect 266 residents residing in the facility at the time of survey.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview and record review, the facility failed to assess for safety of smoking for 1 of 2 sampled residents (Resident #217).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on observation and interviews, the facility failed to ensure an effective call light system for 2 South (24 rooms).

Inspectors wroteBased on observation, interviews and record review, the facility failed to equip corridors with firmly secured an unbroken handrail.