Unity Hospice

“Based on observation, staff interview and review of maintenance records on February 4, 2026, Unity Hospice, DePere, WI failed to meet the following fire protection and building safety standards for safety to patients. Findings include K 0293 Exit Signage - Maintenance and TestingK 0341 Fire Alarm System InstallationK 0345 Fire Alarm System - Maintenance and TestingK 0363 Corridor Doors42CFR 418.110(d) Standard: Fire Protection42CFR 418.110(e) Standard: Building Safety As a result of the above deficiency, 42 CFR Subpart 418.110 Condition of Participation: Hospices that provide inpatient care directly was NOT MET. See K-tags for details of the specific findings.”

“Based on record review and staff interview, the facility failed to include required contact information in the emergency preparedness plan per 42 CFR section 418.113(c)(2). This deficient practice could affect all patients, as well as undetermined number of staff and visitors. Findings include:On 02/04/2026 at 11:39 am, record review of the Emergency Preparedness Plan (EPP) revealed that the contact information for the Federal, State, tribal, regional, and local emergency preparedness staff was not included in the EPP or communication plan. When asked if this contact information was available, Staff E reviewed electronic documents from her computer but was unable to locate and retrieve this information.This finding was confirmed at the time of discovery by concurrent interview with Staff D and Staff E.”

“Based on record review and interview, the facility did not document the monthly inspections of the exit lights in accordance with the requirements of NFPA 101 (2012 edition), sections 19.2.9.1 and 7.10.9.1. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include:On 02/04/2026 at 9:56 am, record review revealed monthly visual inspections for the operation and illumination of the exit lights were not documented for the past (12) months. When asked if the exit lights were visually inspected and documented each month, Staff D replied, “I check exit lights when I check extinguishers and detectors, but it is not documented.”This finding was confirmed at the time of discovery by a concurrent interview with Staff D.”

“Based on observation and interview, the facility failed to install supervised smoke detection in accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.4, 19.3.4.2.1, and 9.6 and NFPA 72 (2010 edition), sections 17.7.3, 17.7.4, and 17.7.4.1. This deficient practice could affect 6 of 12 patients, as well as an undetermined number of staff and visitors. Findings include:On 02/04/2026 at 12:47 pm, observation in the Fireplace Room B138 revealed that (2) ceiling mounted smoke detectors were located within 28-inches of the air flow of 6-inch by 24-inch air supply diffusers. One detector was located on the south side of the room, and the other was on the north side of the room. The facility had no documentation to confirm that the detector was installed per manufacturer’s recommendations.This finding was confirmed at the time of discovery by a concurrent interview with Staff D.”

“Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.4, 9.6.1.3, and 9.6.1.5; NFPA 72 (2010 edition), sections 14.3.1, 14.4.2.2, 14.4.5, 14.6, and 14.6.2.4. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include:On 02/04/2026 at 9:27 am, record review of fire alarm inspection and testing revealed no documentation that the semi-annual visual inspections of initiating devices (duct detectors, electro-magnetic door hold-opens, pull stations, heat detectors, smoke detectors) or testing of the fire system batteries was performed in the past 12 months. When asked if the semi-annual inspection had been performed, Staff D replied “I do a visual inspection for any damage of devices, but I don’t document it. I do not do any battery testing.”This finding was confirmed at the time of discovery by a concurrent interview with Staff D.”

“Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke in accordance with NFPA 101 (2012 edition) sections 19.3.6.3.1, 19.3.6.3.5, 19.3.2.4 and 8.7; NFPA 99 (2012 edition), sections 11.3.1, 5.1.3.3.2. This deficient practice could affect 0 of 12 patients, as well as an undetermined number of staff and visitors. Findings include:On 02/04/2026 at 12:30 pm, observation in the basement of the 45-minute rated fire door between the Oxygen Central Supply room and the emergency egress corridor revealed that when the door was opened and released to close, the door would not fully close and latch for (3) of (3) attempts. The basement is only accessed by an exterior door at grade, and no patients have access to the basement.This finding was confirmed at the time of discovery by a concurrent interview with Staff D.”

“Based on observation, record review and interview, the agency nurse failed to follow standards of practice for disposal of patient medication in 1 of 1 inpatient observations (Patient #6) in a total of 6 observations of patient care.Findings include: Record review of agency policy titled “Medications-Management” dated 12/2022 revealed “Procedures: 15. Medications that are no longer needed are disposed of in accordance with accepted standards of practice.”During an observation and interview with RN B on 02/04/2026 at 9:15 AM, RN B went into the locked pharmacy room and retrieved the medication bottle Atorvastatin for Patient #6 from a locked medication cart. RN B removed the label from the medication bottle and threw the label into a black medication disposal bin located behind RN B on the other side of the pharmacy room. RN B then threw the medication bottle, which was 1/4 full of white pills, into a trash bin to the right of the medication cart. RN B stated that when a patient medication is discontinued, B will throw the label into the designated medication bin and throw the medication bottle away.During an interview with Team Leader C on 02/04/2026 at 9:50 AM, Team Leader C stated, “There is a designated medication disposal box located in the pharmacy area. Controlled substances go into a Drug Buster and anything else goes into the designated medication disposal bin. Except if empty, it goes into the garbage.” Team Leader C stated RN B should have put the medication bottle in the designated bin.”