Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Unger Park Post Acute during CMS and state inspections, most recent first.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Surveyors found that the facility did not maintain resident dignity in grooming and dining. A cognitively intact female resident with psychiatric diagnoses and a need for assistance with personal care was repeatedly observed in common areas with long white hairs on her chin, with documentation showing recent bed baths but no shaving, and she reported staff did not shave or offer to shave her chin. A CNA confirmed the presence of the chin hair and that the resident would allow shaving. In a separate instance, a visually impaired resident with dementia who was dependent for eating was assisted by a CNA who stood beside the resident for the entire meal rather than sitting, despite the CNA stating she normally sits to assist with feeding. These practices conflicted with the facility’s dignity policy requiring grooming as residents wish and a dignified dining experience.
Surveyors found that the facility did not maintain a homelike environment when a hole with exposed wiring remained in the dining room ceiling over several days while residents ate beneath it, and meal service was disorganized, with trays left intact, tables not served together, and one resident taking food from another’s uncovered tray before staff intervened. In addition, a resident with a pressure mattress and multiple medical conditions repeatedly had an ill-fitting bed sheet that did not fully cover the mattress, causing discomfort, a problem acknowledged by the resident’s representative and the Maintenance Director.
A dietary aide was hired and began working without a completed BCI background check, as confirmed by review of employee files, the BCI log, and staff interview. Facility policy requires background checks to be completed before employment for all direct access staff, but this process was not followed, potentially affecting all residents.
The facility failed to prevent and respond to an increased pattern of UTIs, affecting two residents with multiple infections identified as E. coli. Despite the infection control logs showing at least 58 residents with UTIs not present upon admission, no specific in-services for UTI prevention were conducted. The infection preventionist admitted the facility did not recognize or address the increase in UTIs, contrary to their policy requiring ongoing surveillance and preventative interventions.
The facility failed to conduct timely care conferences for several residents, affecting six out of 19 reviewed. Residents with various medical conditions, including hemiplegia, PTSD, and dementia, missed scheduled care conferences in specific months. Interviews with staff confirmed the absence of these conferences, and the facility's policy encouraged resident and family participation in care planning, but there was no documentation of attempts or explanations for the missed conferences.
The facility failed to provide adequate activities for residents in the memory care unit, affecting all 13 residents. Observations showed a lack of engaging activities and an absence of an activity calendar. Interviews revealed that residents were often unaware of activities, and staff struggled to conduct activities due to understaffing and limited involvement from the activity director.
The facility failed to ensure required physician visits for several residents, as mandated by policy. Despite frequent visits by NPs, some residents did not receive physician visits for extended periods, affecting those with conditions like Alzheimer's and chronic obstructive pulmonary disease. Interviews confirmed the lack of adherence to the policy, which requires physician visits every 30 days for the first 90 days and every 60 days thereafter.
The facility failed to provide palatable and appetizing meals to residents, as observed through resident and staff interviews. Issues included cold food, dry chicken, and mushy Brussel sprouts, affecting residents with various medical conditions. The Dietary Manager confirmed the food quality issues, which did not align with the facility's policy on food preparation and serving.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents except one. Observations revealed splattered food debris and chipping walls near the dishwasher, and paint strips hanging from the ventilation hood. The Dietary Manager and District Manager confirmed these findings, which violated the facility's Environment policy requiring cleanliness in food preparation and service areas.
The facility failed to maintain the kitchen's walk-in and reach-in coolers at safe temperatures, with readings consistently above the required 41 degrees Fahrenheit. This affected all residents except one who did not receive meals from the kitchen. Various food items were stored at unsafe temperatures, violating the facility's food storage policy.
A facility failed to ensure a resident's code status was consistent across records, with a DNRCCA documented in the paper chart and a full code order in the EMR. The resident, who was cognitively intact, had a documented DNRCCA status, but the EMR was not updated, as confirmed by an RN. The facility's policy requires annual review and updates of advance directives, which was not adhered to, leading to this discrepancy.
A resident reported that their bathroom was not cleaned regularly, and observations confirmed the presence of dried feces, a towel, and a paper towel in the bathroom. A CNA verified these conditions, acknowledging that the bathrooms were supposed to be cleaned daily, indicating a failure to maintain a clean and safe environment.
A facility failed to administer tube feedings according to physician orders for a resident with severe malnutrition and other medical conditions. The resident's tube feeding was observed running outside the prescribed hours, and the MAR showed missed feedings on several days. Staff interviews revealed confusion about the feeding schedule, leading to improper administration.
A resident with type two diabetes did not receive insulin dose adjustments as ordered by the physician, leading to significant medication errors. The facility's medication administration record showed fixed doses were given without adjustments based on blood sugar levels, as confirmed by the DON and the physician.
The facility did not complete reference checks for four new employees, including an RN, a SW/AA, a MT, and a CNA. This was confirmed through personnel records and an interview with the HRD, potentially impacting all 74 residents.
A resident with cognitive impairments was found inappropriately touching another resident who was unable to consent, due to a failure in monitoring and care planning. The incident was reported to the police as a sexual assault, but the facility marked it as unsubstantiated physical abuse. The care plan for the resident with behavioral issues lacked new interventions post-incident.
A facility failed to ensure medications were fully ingested, affecting a resident with Alzheimer's and potentially impacting others. A resident was found with partially dissolved pills left at the bedside, contrary to facility policy. Staff interviews revealed inconsistencies, with an LPN initially denying but later confirming the oversight.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Failure to Maintain Resident Dignity in Grooming and Dining Assistance
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and personal grooming, and to provide a dignified dining experience. One cognitively intact female resident with paranoid schizophrenia, depression, anxiety, and a need for assistance with personal care was documented as requiring partial/moderate assistance for bathing/showering and setup or clean-up assistance for personal hygiene. Shower documentation for two dates showed she received bed baths with no shaving documented. Over multiple observations on consecutive days, surveyors noted long white hairs on the resident’s chin while she was in common areas, including sitting by the nurse’s station. The resident stated she sometimes shaved her chin herself, that staff did not shave it for her, and that staff did not offer to shave the hairs. A CNA reported that female residents were shaved on shower days and confirmed this resident would allow staff to shave her chin and that she had long white hairs present. The facility also failed to ensure a dignified dining experience for a resident with Alzheimer’s disease with early onset, dementia with agitation, severely impaired vision, and dependence on staff for eating. Physician orders and the MDS indicated the resident required assistance with feeding. During a meal observation, a CNA stood beside the resident for the entire meal while assisting with eating, rather than sitting. In a subsequent interview, the CNA acknowledged that she normally sits down to assist residents with meals, verified that she stood beside this resident during the observed meal, and explained that because the resident was blind, staff could hand finger foods but had to physically assist with the rest of the meal. These actions and inactions were inconsistent with the facility’s dignity policy, which states residents are to be groomed as they wish and provided with a dignified dining experience.
Failure to Maintain Homelike Environment, Dining Experience, and Proper Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Homelike Environment policy. Surveyors observed a missing tile in the dining room drop ceiling on multiple occasions, creating a rectangular hole with visible wiring exposed. This condition persisted over several days, including during meal service when residents were seated and eating directly beneath the opening. One resident with dementia, congestive heart failure, and type 2 diabetes, who had moderate cognitive impairment, noticed the hole and reported feeling worried about the ceiling falling and people getting hurt. A staff member confirmed the presence of the hole and stated that maintenance had been doing work above the ceiling but could not say how long the hole had been there. The facility also failed to ensure a homelike dining experience for residents who routinely ate meals in the dining room. During a lunch observation, staff delivered meal trays in a random order and left the food on the trays rather than placing plates and drinks on the tables. Residents at the same table did not receive their meals at the same time, with one resident receiving a tray significantly earlier than tablemates. While trays sat uncovered in front of residents waiting for assistance, another resident turned her wheelchair away from her own table and reached over to grab a hamburger from another resident’s tray. Staff intervened, removed the touched plate, and replaced it, but the initial service pattern and handling of trays were confirmed by the Business Office Manager, who stated that plates, drinks, and silverware were not normally removed from trays and that tables were not served together, and by the Dietary Director, who stated that staff should have removed items from trays and served tables together. Additionally, the facility did not provide comfortable and well-fitting bed linens for a resident with a history of cerebral infarction due to occlusion or stenosis of a small artery, type II diabetes, and a cognitive communication deficit, who had moderate cognitive impairment. On two separate observations, the resident’s pressure mattress was not fully covered by the bed sheet, leaving portions of the mattress exposed near the resident’s head. The resident’s representative reported that the sheets tended to slide off the mattress, and the resident stated that the sheets were bothersome, did not fit correctly, and that this issue had been reported to staff without resolution. The Maintenance Director confirmed that the sheet was not covering the mattress and identified this as a problem related to the pressure mattress in use. These conditions were inconsistent with the facility’s policy requiring clean bed linens in good condition as part of a comfortable, homelike environment.
Failure to Complete Employee Background Checks Prior to Employment
Penalty
Summary
The facility failed to ensure that employee background checks were completed prior to employment, as required by facility policy. Specifically, review of an employee file for a dietary aide revealed that the individual began employment without evidence of a completed Bureau of Criminal Investigation (BCI) background check. The BCI log did not show that a background check was performed for this employee, and the Human Resource Director confirmed that the check had not been completed. Facility policy mandates that background and criminal checks, including fingerprinting, must be initiated within two days of an employment offer and completed before the employee starts work. This lapse had the potential to affect all 56 residents in the facility.
Failure to Prevent and Respond to Increased UTIs
Penalty
Summary
The facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs) among its residents, specifically affecting two residents who were reviewed for UTIs. Resident #16, who was cognitively intact and frequently incontinent of urine, experienced multiple UTIs over a period of several months, with urine cultures consistently identifying Escherichia coli (E. coli). Similarly, Resident #60, who was always continent of bladder and bowel, also had multiple UTIs with E. coli identified in the urine cultures. The infection control logs indicated that at least 58 residents were diagnosed with UTIs that were not present upon admission. The facility's infection prevention and control program was found lacking, as there were no in-services conducted specifically for the prevention of UTIs during the review period. Although a handwashing in-service was conducted, it was related to another infection control concern and not the increase in UTIs or E. coli. The facility's infection preventionist acknowledged the lack of recognition and response to the increase in UTIs, which was contrary to the facility's policy that required ongoing surveillance and preventative interventions for significant infections.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences for several residents, affecting six out of the 19 residents reviewed. These residents had various medical conditions, including hemiplegia, PTSD, bipolar disorder, schizophrenia, anxiety, dementia, COPD, diabetes, and depression. The review of medical records and progress notes revealed that care conferences were not held as required in specific months for each resident. For instance, Resident #07 did not have care conferences in May and August 2024, while Resident #08 missed a conference in July 2024. Similarly, other residents also missed their scheduled care conferences in different months. Interviews with facility staff, including the Social Worker/Administrative Assistant and the Director of Nursing, confirmed the absence of these care conferences. The facility's policy on care planning indicated that the interdisciplinary team was responsible for developing care plans and encouraged resident and family participation. However, there was no documented evidence of care conferences being held or attempted for the affected residents, nor was there documentation explaining why participation was not practicable.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to ensure that activities on the memory care unit met the needs and preferences of all 13 residents. Observations revealed that there was no activity calendar posted in the memory care unit, and residents were often left without engaging activities. For instance, during several observations, residents were found in common areas with a television playing, but none were actively watching or participating in any structured activities. Interviews with residents and staff indicated a lack of awareness and participation in activities, with one resident expressing boredom and another unaware of scheduled activities. The care plans for residents, such as Resident #04 and Resident #175, highlighted the need for structured activities to prevent social isolation and engage residents with cognitive impairments. However, the facility's activity program did not adequately address these needs. The activity director admitted to limited presence in the memory care unit and a lack of specialized training for memory care activities. The activity calendar, when eventually posted, included basic daily routines but lacked engaging and varied activities tailored to the residents' needs. Staff interviews revealed that the memory care unit was often understaffed, with only two CNAs available, making it challenging to conduct activities, especially when managing residents' behaviors. The activity director's limited involvement and the absence of a consistent and engaging activity schedule contributed to the deficiency in meeting the residents' needs for meaningful engagement and social interaction.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed as required for five out of nine residents reviewed. The policy mandates that attending physicians must visit residents at least once every 30 days for the first 90 days following admission, and then every 60 days thereafter. However, the review of medical records and interviews with staff revealed that several residents did not receive the required physician visits. For instance, one resident was seen by a nurse practitioner monthly but had no documented physician visit for nearly ten months. Another resident, with severe cognitive impairment, was seen by a physician only three times over several months, despite frequent visits by a nurse practitioner. The deficiency affected residents with various medical conditions, including fibromyalgia, Alzheimer's, chronic obstructive pulmonary disease, and major depressive disorder. Interviews with the facility's administrator and assistant director of nursing confirmed the lack of physician visits as per the policy. The facility's policy allows for alternating visits by a physician assistant or nurse practitioner after the initial 90 days, but the schedule must not exceed every 60 days. The absence of documented physician visits for the affected residents indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that residents received food that was palatable and appetizing, which met their nutritional recommendations. This deficiency was identified through observations, resident interviews, and staff interviews. Four residents were affected, all of whom reported issues with the food served during lunch. The issues included food being served cold, chicken being too dry to chew, and Brussel sprouts being mushy or lacking taste. The Dietary Manager confirmed these observations, noting that the chicken was dry and the food temperatures were not consistently maintained at the desired levels. The medical records of the affected residents revealed various diagnoses, including type 2 diabetes mellitus, paranoid schizophrenia, chronic obstructive pulmonary disease, and dementia. Despite these conditions, the residents were cognitively intact and able to articulate their dissatisfaction with the meals. The facility's Food Quality and Palatability policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature. However, the observations and interviews indicated that the facility did not adhere to this policy, resulting in the identified deficiency.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, affecting all residents except one who did not receive meals from the kitchen. During an observation of the kitchen, it was found that the wall across from the dishwasher had splattered food debris and parts of the wall were chipping. The Dietary Manager confirmed these findings. Additionally, the ventilation hood above the clean pan rack and stove top had paint strips hanging down, which the Dietary Manager attributed to excessive cleaning. A follow-up observation with the District Manager confirmed that the white paint strips were chipping from the ventilation hood. The facility's Environment policy required all food preparation and service areas to be maintained in a clean and sanitary condition, which was not adhered to in this instance.
Failure to Maintain Safe Cooler Temperatures
Penalty
Summary
The facility failed to ensure that the kitchen's walk-in cooler and reach-in cooler were functioning in a safe and operable condition, which had the potential to affect all residents except one who did not receive meals from the kitchen. During an observation on December 16, 2024, the reach-in cooler was found to have an ambient internal temperature of 44 degrees Fahrenheit, and the walk-in cooler had a temperature of 47 degrees Fahrenheit. These temperatures were verified by the Dietary Manager (DM) #333. Further inspection revealed that various food items stored in the walk-in cooler, such as cottage cheese, cream cheese, whole milk, pre-sliced cheese, sliced ham, homemade coleslaw, and buffet ham log, were also above the required temperature of 41 degrees Fahrenheit. The temperature logs for the walk-in cooler showed consistent readings above the required 41 degrees Fahrenheit over several days in December 2024, with temperatures ranging from 42 to 47 degrees Fahrenheit. The facility's policy on food storage mandates that all perishable foods be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. The Equipment policy also requires that all food service equipment be clean, sanitary, and in proper working order. Despite these policies, the facility did not maintain the coolers at the appropriate temperatures, leading to the deficiency.
Discrepancy in Resident Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status of a resident matched across different records, leading to a discrepancy in the medical documentation. Resident #12, who was cognitively intact, had a documented code status of Do Not Resuscitate Comfort Care Arrest (DNRCCA) in the hard/paper chart dated 10/23/24. However, the electronic medical record (EMR) contained a physician's order dated 12/16/24 indicating the resident was a full code. This inconsistency was confirmed during an interview with Registered Nurse (RN) #230, who acknowledged the discrepancy and stated that the order in the EMR had not been updated to reflect the resident's DNRCCA status. The facility's policy on advance directives requires the interdisciplinary team to review and update the resident's advance directives annually during the assessment process, ensuring that the directives align with the resident's current wishes. However, in this case, the policy was not followed, resulting in conflicting information between the paper chart and the EMR. This oversight affected the accuracy of the resident's medical records and could potentially impact the care provided to the resident.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as required. A resident, who was cognitively intact and always continent of bladder and bowel, reported that their bathroom was not cleaned regularly. During an observation, dried feces were found on the lower left side of the toilet, along with a towel on the floor and a brown paper towel behind the toilet. A follow-up observation confirmed that these conditions remained unchanged, and a small puddle was also noted in front of the toilet. A CNA verified these conditions and acknowledged that the bathrooms were supposed to be cleaned daily, indicating a lapse in maintaining the cleanliness of the resident's environment.
Failure to Administer Tube Feedings Per Physician Orders
Penalty
Summary
The facility failed to administer tube feedings in accordance with physician orders for a resident with multiple medical conditions, including cerebral infarction and severe protein-calorie malnutrition. The resident was prescribed Osmolite 1.2 Cal via nasogastric tube at 80 mL per hour from 6:00 P.M. to 6:00 A.M. daily. However, on the morning of December 16, 2024, the tube feeding was observed to be running at 10:25 A.M., contrary to the physician's order. Interviews revealed that the tube feeding was mistakenly connected by a staff member who believed it was supposed to be administered during the day. Additionally, the medication administration record (MAR) indicated that the resident did not receive their tube feeding as ordered on December 11, 12, and 13, 2024. The Director of Nursing confirmed the discrepancies in the MAR and acknowledged the failure to administer the tube feeding per the physician's order on those dates. This oversight in following the prescribed feeding schedule potentially impacted the resident's nutritional intake and appetite during mealtimes.
Failure to Adjust Insulin Doses as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in significant medication errors for a resident with multiple diagnoses, including type two diabetes. The resident was cognitively intact and had an active physician order for Humulin 70/30 insulin, which required dose adjustments based on blood sugar levels. However, the medication administration record for December 2024 showed that the nurses consistently signed off on administering fixed doses of insulin without adjusting them according to the physician's orders and the resident's blood sugar readings. The Director of Nursing (DON) confirmed that the insulin order was not updated after the physician made changes, and acknowledged that the order was confusing. The DON verified that the insulin doses should have been adjusted on specific dates in December, but the facility could not provide evidence that these adjustments were made. An interview with the physician further confirmed that the insulin should have been adjusted according to the active orders, indicating a failure to follow the prescribed medication regimen for the resident.
Failure to Complete Reference Checks for New Employees
Penalty
Summary
The facility failed to ensure that reference checks were completed for four new employees, which included a Registered Nurse, a Social Worker/Administrative Assistant, a Medication Technician, and a Certified Nursing Assistant. This deficiency was identified through a review of employee personnel records, background check logs, and staff interviews. The absence of documented evidence of reference checks for these employees was confirmed during an interview with the Human Resource Director. This oversight had the potential to affect all 74 residents residing in the facility.
Failure to Prevent Resident-to-Resident Sexual Altercation
Penalty
Summary
The facility failed to prevent an inappropriate resident-to-resident altercation that was sexual in nature, affecting one resident. Resident #105, who was admitted for a short-term respite stay, was involved in an incident where another resident, Resident #82, was found in her room with his hand up her dress on her breast area. Resident #105 had a history of hemiplegia, cerebrovascular disease, and was on psychotropic medications for depression. She required substantial assistance for mobility and was unable to provide a statement or recall the incident due to her cognitive state. Resident #82, who had diagnoses of paranoid schizophrenia and bipolar II disorder, was found to have impaired cognition and socially inappropriate behaviors. On the day of the incident, Resident #82 was observed by LPN #63 to be pacing the hallways, entering and exiting rooms, and eventually lying in bed with Resident #105. Despite being redirected earlier, Resident #82 was found groping Resident #105, which led to immediate intervention by LPN #63. The facility's investigation revealed that Resident #82 had a recent change in cognition and was experiencing a decline in mental health, which was not adequately addressed in his care plan. The facility's response included notifying the police, who documented the incident as a sexual assault due to Resident #105's inability to consent. The facility's investigation and documentation, however, marked the incident as physical abuse and unsubstantiated. The care plan for Resident #82 did not include new interventions for sexual behaviors after the incident, and the facility's policy on abuse and neglect was not effectively implemented to prevent the incident. The deficiency highlights a failure in monitoring and care planning for residents with known behavioral issues.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were fully ingested and not left at the bedside, affecting one resident and potentially impacting eight others who were independently mobile and cognitively impaired. Resident #21, who was admitted with Alzheimer's and dementia with behavioral disturbance, was observed with a plastic medication cup containing four partially dissolved pills on her overbed table. This observation was made despite the facility's policy requiring that residents be observed to ensure complete ingestion of medications. Interviews with staff revealed inconsistencies in medication administration practices. A State Tested Nursing Assistant confirmed the presence of the pills, noting that such occurrences were not uncommon. An LPN initially denied leaving medications at the bedside but later acknowledged that the medications were from her administration, as the handwriting on the cup was hers. The LPN had relied on the resident's non-verbal indication that she had taken the pills, which was not in compliance with the facility's medication administration guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bucyrus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Of Bucyrus Center Fo | 2.5 mi | — | 3 | 0 |
| Galion Pointe, Llc | 10.9 mi | — | 0 | 0 |
| Galion Meadows Skilled Nursing And Rehabilitation | 11.2 mi | — | 15 | 0 |
| Mill Creek Nursing & Rehabilitation | 11.5 mi | — | 0 | 0 |
| Crestline Rehabilitation And Nursing Center | 13.3 mi | — | 0 | 0 |
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