Unity Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Unity Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 14, 2021

  Based on observation, interviews and records review the facility failed to provide proper care and supervision to prevent falls for one resident (Resident #1) out of three sampled residents that were reviewed for accidents and falls during a complaint investigation survey. Resident #1 a vulnerable resident with known wandering behaviors required a wheelchair as mobility device. While unsupervised on the second floor approximately 300 feet away from his unit, Resident #1 pushed open the fire exit door, exited through the fire exit door, and descended the first flight of stairs (7 steps) to the landing below, where he was found by staff. […]

• No harm, potential for more than minimal, widespreadF803Nov 18, 2022

  Based 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). The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular Diet consistency had 3 ounces of honey-glazed ham,4 ounces of red cabbage, and 4 ounces of seasoned roasted potatoes. The Diet Type Report provided by the facility showed that 145 residents are on a Regular diet consistency. In an observation conducted on 11/15/22 at 1:40 PM, Resident #189 was noted in his room with the lunch tray at his bedside. […]

• No harm, potential for more than minimal, widespreadF910Nov 18, 2022

  Based 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. The findings included: Review of a Memo provided to the surveyors by the facility's Administrator revealed the following: 81 rooms in the facility are semi-private rooms. Of these, 58 measure 157 square feet-which equates to less than the required 80 square feet per resident. […]

• No harm, potential for more than minimal, patternF908Feb 22, 2024

  Based 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. The findings included: Observation on 02/21/2024 at 07:25 AM revealed that on the second floor there were six (6) mechanical lifts working to take care of 91 residents who were totally dependent on the equipment. On the first floor five mechanical lifts worked to take care of 71 residents who were totally dependent on the equipment. In total the facility had five mechanical lifts broken. […]

• No harm, potential for more than minimal, patternF808Nov 18, 2022

  Based 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. The findings included: A review of the facility's cycle menu showed that on 11/15/22, the following was provided: the Regular diet consistency had honey-glazed ham, red cabbage, and seasoned roasted potatoes. […]