Union House Nursing Home
For profit - Limited Liability company
44 Beds
Independent
Data: November 2025
Trust Grade
25/100
#18 of 33 in VT
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Union House Nursing Home has received a Trust Grade of F, indicating significant concerns about the facility's care and operations. Ranking #18 out of 33 in Vermont places it in the bottom half of all state facilities, and it's the lowest-ranked option in Orleans County. While there has been an improvement trend, with issues decreasing from 14 in 2023 to 7 in 2024, the facility still faces serious challenges. Staffing is a concern, with a 74% turnover rate, which is much higher than the state average, suggesting instability among caregivers. Additionally, the facility has encountered serious issues, including failing to implement a personalized care plan for a resident with a history of trauma, leading to inappropriate care during bathing, and a physical altercation between residents that resulted in injury. Although RN coverage is average, the facility has accrued fines totaling $62,020, which may indicate ongoing compliance problems. Overall, while there are some positive trends, the facility's significant weaknesses raise concerns for families considering this nursing home.
- Trust Score
- F
- In Vermont
- #18/33
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 74% turnover. Very high, 26 points above average. Constant new faces learning your loved one's needs.
- Penalties ○ Average
- $62,020 in fines. Higher than 50% of Vermont facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Vermont. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 46%
Review needed
14 → 7 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 14 issues
2024: 7 issues
The Good
-
Licensed Facility · Meets state certification requirements
-
No fines on record
This facility meets basic licensing requirements.
The Bad
3-Star Overall Rating
Near Vermont average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 74%
28pts above Vermont avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $62,020
Above median ($33,413)
Moderate penalties - review what triggered them
Staff turnover is very high (74%)
26 points above Vermont average of 48%
The Ugly 25 deficiencies on record
3 actual harm
Dec 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that two residents [#39 & #11] of 21 sampled residents remai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that two residents [#39 & #11] of 21 sampled residents remained as free of accident hazards as possible regarding adequate supervision, implementing interventions to reduce hazards and risks, and assessing interventions for effectiveness.
Findings include:
1.) Per record review, Res. #39 was admitted to the facility with diagnoses that include Alzheimer's disease, anxiety disorder, and muscle weakness.
A Quarterly Fall Risk assessment dated [DATE] identified the resident as a High Risk for falls, determining the resident was disoriented, had a history of recent falls, with poor vision, poor safety judgement and attempted to get out bed and chairs unsafely.
Review of Res.#39's Care Plan identifies the resident as is at risk for falls due to unsteady gait when tired, Alzheimer's disease, and history of falls.
Record review reveals Resident #39 had sustained 4 falls in the past 2 months, including 2 falls on back-to-back days on 11/23 & 11/24/24. Further review revealed Res.#39 suffered a 5th fall on 12/5/24. Review of Progress Notes record the resident was Combative at care, screaming, hitting, and pinching. This evening, [staff] was standing near the nurses' station, [Res.#39] was observed watching a Christmas movie and suddenly standing up from the wheelchair in a jumpy way and landing on [h/her] palms and knees on the floor before staff were able to intervene. Resident was combative during assessment, screaming and trying to grab onto [staff]. In the days following the fall, Progress Notes [dated 12/7/24] record Res.#39 continues to be combative with care, as well as with redirection, with interventions such as Reapproach/reassurance assessed as ineffective.
Per review of the facility's Fall and Fall Risk, Managing policy, under the policy's Resident-Centered Approaches to Managing Falls and Fall Risk section is If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Additionally, under Monitoring Subsequent Falls and Fall Risk is If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. [Policy version 1.2 (H5MAPL0313) revised 2018].
Per interview with the Director of Nursing [DON] on 12/17/24 at 12:38 PM, the DON confirmed the facility's policy is to review a resident's Care Plan after each fall and add additional interventions to prevent future falls. Per record review and confirmed during the DON interview, there were no new interventions added to Res. #39's Care Plan after the fall on 12/5/24 to prevent the resident from falling again.
2.) Per record review, Res.#11 was admitted to the facility with diagnoses that include:
dementia, schizophrenia, anxiety, depression, and psychosis, as well as difficulty in walking, muscle weakness, muscle wasting, and unsteadiness on [h/her] feet.
Review of Res.#11's Care Plan identifies the resident as at risk for falls due to: poor safety awareness due to Schizoaffective Disorder, Anxiety, Depression, and Psychosis, poor posture when ambulating, and using furniture to walk.
Record review reveals Resident #11 had sustained 3 falls in the past 4 months, including a fall with bruising to their forehead. Further review revealed Res.#39 suffered a 4th fall on 12/5/24. Review of Progress Notes record the resident was found sitting on [h/her] buttocks in [h/her] room, in between bathroom door and [h/her] wheelchair in front of [h/her].
Per interview with the Director of Nursing [DON] on 12/17/24 at 12:38 PM, the DON confirmed the facility's policy is to review a resident's Care Plan after each fall and add additional interventions to prevent future falls. Per record review and confirmed during the DON interview, there were no new interventions added to Res. #11's Care Plan after the fall on 12/5/24 to prevent the resident from falling again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the...
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Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 21 sampled residents (Resident #20). Findings include:
Per observation on 12/17/24 at 1:37 PM Resident #20 unwrapped a gauze dressing covering a wound on their hand. The dressing was visibly soiled with blood. Resident #20 unwrapped the gauze until it was dangling from their hand and touching the floor of the dining area/TV room. At this point a staff Licensed Nursing Assistant [LNA] who was not wearing gloves began to redress the wound with the same gauze. Moments later a staff Registered Nurse [RN] came over to assist. The RN providing care to the resident was also not wearing gloves. Once Resident #20's hand was fully wrapped the staff RN secured the gauze with the original tape which had been stuck to the arm of Resident #20's chair.
In an interview with the facility's Director of Nursing [DON] on 12/18/24 at 1:36 PM the DON confirmed that the soiled dressings that had been in contact with the floor should not have been reused to dress the wounds on Resident #20.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to create and implement a policy related to national background checks...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to create and implement a policy related to national background checks for their employees. The facility also did not complete national background checks for 19 of the 22 Licensed Nursing Assistants (LNAs) employed by the facility. Findings include:
Record review of 5 LNA human resource files revealed there was no evidence of national background checks for 3 of the LNAs sampled. The facility provided an additional list of all LNAs employed at the facility and confirmed that only three of the 22 LNAs had evidence of national background checks. Per interview with the Clinical Lead Registered Nurse (RN) on 12/18/2024 at approximately 12:00 PM, s/he stated that the facility did not complete national background checks for their employed LNAs.
Per record review, a memo from [Department of Aging and Independent Living] was sent out to nursing facilities on October 5, 2022, that states, 1. Prior to employing an individual and at least annually thereafter, a Facility must query the following entities regarding the prospective / current employee: .Agency providing a national criminal background check . To check whether the individual is barred from employment based on prior convictions in any state .2. Under [NAME] and federal laws and regulations, a Facility must decline to employ a prospective or current employee with: .Criminal convictions for the abuse/exploitation/neglect of a vulnerable adult or child in any state . In addition to the prohibitions mentioned above, [NAME] laws prohibit long-term care facilities from employing individuals with criminal convictions relating to bodily injury, theft or misuse of funds or property, and/or crimes inimical to the public welfare.
Per review of the facility policy titled Abuse Prevention Program last revised 12/2016 states the following As part of the resident abuse prevention, the administration will . Conduct employee background checks .Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of residents. The policy did not specify the requirement for national background checks.
Per interview with the Clinical Lead RN on 12/18/2024 at 2:00 PM, s/he confirmed that s/he was not aware of the memo and that the abuse policy had not been updated to reflect requirement to complete at least one national background check for their employees. S/He also confirmed that the national background checks had not been done for the employees and they should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure Care Plan interventions were implemented for three residents [Resident #27, Resident #39, and Resident #294] of 21 sampled residents...
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Based on interview and record review, the facility failed to ensure Care Plan interventions were implemented for three residents [Resident #27, Resident #39, and Resident #294] of 21 sampled residents.
Findings include:
1. Per review of the medical record for Res. #27, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to immobility, urinary incontinence, a Care Plan goal that states Resident will be free from alteration in skin integrity and the Care Plan has interventions that include Weekly skin check by Licensed Nurse. All of the aforementioned Care Plans were initiated on 6/27/24 and have not been revised.
A review of nursing documentation titled Assessments for Resident #27 showed skin checks done on 6/22/24, 7/23/24 and 8/27/24, only 3 times in 24 weeks.
2. Per review of the medical record for Res. #39, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to incontinence, immobility, a Care Plan goal that states Resident will be free from alteration in skin integrity and the Care Plan has interventions that include Weekly skin check by Licensed Nurse. All of the aforementioned Care Plans were initiated on 7/31/24 and have not been revised.
A review of nursing documentation titled Assessments for Resident #39 showed a skin check done on 7/16/24, only once in 19 weeks.
3. Per review of the medical record for Res. #294, the resident has a Care Plan focus that states Resident is at risk for alteration in skin integrity related to incontinence, immobility, a Care Plan goal that states Resident will be free from alteration in skin integrity and the Care Plan has interventions that include Weekly skin check by Licensed Nurse. All of the aforementioned Care Plans were initiated on 7/23/24 and have not been revised.
A review of nursing documentation titled Assessments for Resident #294 showed skin checks done on 7/11/24 and 12/10/24, only twice in 20 weeks.
During an interview on 12/17/24 at 12:38 PM with a Licensed Practical Nurse and the Director of Nursing, both staff members confirmed interventions of Weekly skin checks by a Licensed Nurse to prevent alterations in skin integrity were not implemented for Residents #27, #39, and #294 per their plans of care.
May 2024
1 deficiency
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Resident Rights
(Tag F0550)
Minor procedural issue · This affected most or all residents
Based on observation and interview, the facility failed to ensure each resident has a right to self-determination and access to persons and services outside of the facility by locking all doors to the...
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Based on observation and interview, the facility failed to ensure each resident has a right to self-determination and access to persons and services outside of the facility by locking all doors to the facility 24 hours a day, seven days a week. By creating a locked facility, there is a failure to ensure the right of each resident to exercise their rights as a citizen (or resident) of the United States or make personal choices about going outside without interference. This can potentially affect all residents of the facility and all visitors, including family, legal representatives, and advocates.
During an observation on 5/15/24 at 9:20 AM, this surveyor encountered a barrier to entry. The front door to the facility was locked. The only way to gain access was to press a doorbell, which alerted the staff. A staff member then had to come and physically open the door. The staff member explained that to exit the facility, a staff member would have to access a keypad on the side of the door and enter a code to open the door
.
Per observation on 5/15/24 at 9:40 AM, another entrance to the facility is located on a wing that houses resident rooms and egresses out to a porch. This door is locked with a keypad panel on the side and requires a code to open it.
Per interview on 5/15/24 at 10:00 AM, the Director of Nursing (DON) stated that only employees can have the codes to open the outside doors; residents may not have access to this code.
Per interview on 5/15/2024 at approximately 10:15 AM, the Administrator and the DON stated that the doors are always locked and have been since they can remember. Per the Administrator, the facility has alert and independent residents in their population. The Administrator could not locate a policy or procedure for the doors being locked or operating a completely locked facility. The DON stated that only employees know the code. When asked if there is a process for assessing residents and ensuring those without safety risks can exit the building independently, the DON stated, We had an issue recently; therefore, residents may not have the code. The DON confirmed that residents cannot exit the building anytime without staff assistance.
Per interview, on 5/15/2024 at approximately 12:30 PM, Resident # 1 has resided at the facility since 2014 S/he states that s/he frequently uses the porch outside the locked entrance on the side of the facility. S/he often leaves the facility for outside interests. In the past, s/he was allowed to have the code to the locked doors to exit the facility independently. Recently, the combination was changed, and s/he was told that only the staff would be allowed to have the code. It's not as easy to come and go; I have to call the staff to let me out and then ring the bell to be let back in.
Per interview on 5/15/24 at approximately 12:40, Resident #2 has resided at the facility for the past two years, s/he states s/he enjoys the chairs outside and frequently exits the building to sit in them. S/he states a staff member must access the code on the door to open the door and let him/her out. S/he must ring a bell outside the door and wait for a staff member to open it. S/he does not have access to the door code. I have had to ask the staff for assistance to go out since I have been here.
Per an interview at approximately 2:00 PM, the DON confirmed that only the staff were given the code to open the exterior doors; s/he confirmed that s/he could not locate a policy or procedure addressing the locked facility.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a timely report of an incident of suspected resident-to-resident abuse for 2 of 2 residents (Resident#1 and Resident #2). Findings i...
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Based on interview and record review, the facility failed to ensure a timely report of an incident of suspected resident-to-resident abuse for 2 of 2 residents (Resident#1 and Resident #2). Findings include:
Review of a nursing progress note from 1/8/24 revealed that Resident #1 had approached Resident #5 and started to pull on Resident #5's wheelchair, when s/he told Resident #1 to stop, Resident #1 became angry and slapped Resident #5 on the right arm.
A review of the facility's internal investigation file related to this incident on 1/8/24 revealed confirmation from Adult Protective Services (APS) that a report for this incident had been made to that agency however, there was no documentation or confirmation to support that a report had also been made to the State Agency (SA) which is a requirement.
An interview on 2/20/24 with the Director of Nursing (DON) revealed that s/he believed s/he had reported the incident to APS and to the SA via an email sent through the facility fax machine. However, when this surveyor reviewed the ASPEN Complaint Tracking System (ACTS) on 2/20/24 during a previous facility-report complaint investigation, the report was not found, indicating that the suspected abuse report related to the incident on 1/8/24 had not been submitted to the SA.
On 2/20/24 it was noted that the email address in the initial report was incorrect and therefore the report failed to reach the SA. The DON confirmed that the email address was incorrect on 2/20/24 and further indicated that s/he would send the report to the SA immediately. During the Facility Report Incident (FRI) investigation on 2/28/24, the DON confirmed the report was submitted 44 days late.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure a resident's right to be free from physical abuse for 1 of 3 sampled residents. (Resident #2)
Findings include:
Resident #1 has r...
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Based on interviews and record review, the facility failed to ensure a resident's right to be free from physical abuse for 1 of 3 sampled residents. (Resident #2)
Findings include:
Resident #1 has resided at this facility since 5/19/22, with diagnoses that include Alzheimer's, severe vascular dementia, and an agitation-induced psychotic disorder.
Resident #2 has resided at the facility since 9/19/23 with diagnoses that include end-stage lewy body dementia and parkinsonism.
Per record review, a witnessed resident to resident incident occurred between Resident #1 and Resident #2 on 12/9/23 at 5:47 AM. Resident #2 was standing in the doorway of his/her room, Resident #1 walked up to Resident #2 without speaking and hit her/his legs with her/his cane. Resident #2 attempted to move Resident #1 out of his way by grabbing his shirt; both residents fell to the ground. The investigative summary indicates Resident #2 could recall the incident and stated [Res. #1] whacked me three times on both legs [he/she] starts trouble with everyone.
A review of statements by two witnesses dated 12/9/23 at 5:47 AM reveals that Resident #2 was standing in the doorway of their room when Resident #1 walked by and hit Resident #2 on his/her legs with his/her cane. Both witnesses attempted to intervene and re-direct but were unsuccessful, and the altercation continued, with both residents falling to the floor.
A review of Resident #1's care plan indicates the following interventions initiated on 5/23/22 and reviewed on 12/5/23: utilize staff for one-on-one time if the resident is not easily directable, encourage residents to use his/her cane appropriately and not use it to hit others. Another intervention initiated on 11/9/23 and reviewed on 12/5/23 states, When resident is walking the halls, she/he will be closely monitored to ensure the safety of all residents and allow staff to intervene if s/he swings her/his cane.
A progress note dated 12/13/2023 states that the resident is pacing the halls, swearing at staff, and taking food from another resident's plate; when a redirect was attempted, [s/he] hit staff with a fist and then a cane. Another note dated 12/28/23 reveals resident wandering into several resident rooms, shouting at other residents. Refusing to leave other resident's rooms when staff tried to re-direct, pulled glasses off a female resident's face. Hit a nurse with her/his cane who was attempting to re-direct.
An interview was conducted with another resident on Res.#2's unit, Resident #3, on 1/2/24 at approximately 1:00 p.m. Res. #3 stated that s/he does not leave her/his room often as Resident # 1 will enter the room, rifle through her/his belongings, and often become aggressive, banging the cane on the floor and threatening to hit her/him. S/he feels safer in the room than in a common area.
Per interview on 01/02/24 at 3:30 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing, they confirmed that Resident #1 struck and pushed Resident #2 and struck out at the staff when they tried to intervene or redirect his/her behaviors. The DON confirmed that the facility was not keeping the residents free from physical abuse.
Oct 2023
7 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on record review and interview the facility failed to implement appropriate interventions and provide adequate supervision to prevent accidents and injuries for 1 of 8 sampled residents (Residen...
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Based on record review and interview the facility failed to implement appropriate interventions and provide adequate supervision to prevent accidents and injuries for 1 of 8 sampled residents (Resident #5). Findings include:
Resident #5 was admitted to the facility in May 2023 with diagnoses including heart failure, chronic kidney disease stage 3, major depressive disorder, and chronic obstructive pulmonary disease (a lung disease). A review of the Minimum Data Set (MDS ; an assessment tool used to gather information relevant to care plan development among other uses) dated 7/23/23 reveals in Section B regarding hearing/speech and vision, vision is assessed as highly impaired-object identification in question, but eyes appear to follow objects. Resident #5 has a current Brief Interview for Mental Status (BIMS) score of 13 (this score reflects cognitive function and ranges from 1-15 with lower scores indicating a higher level of impairment).
A record review reveals the following physician documentation dated 10/3/23 . Resident has had 4 falls since last seen. [His/her] falls are mostly unwitnessed and occur in [his/her ] room with the oxygen off! [He/she] is commonly found sitting on [his/her] buttocks. Has had some scrapes from the falls but no significant injuries. Records indicate the falls referenced in the physician's note occurred on 8/20/23, 9/7/23, 9/9/23, 9/10/23.
A progress note dated 10/4/23, the day following the physician's visit, reveals that Resident #5 was observed face down in lying position by the closet door with [his/her] walker beside [him/her]. The resident was assessed and stated that [he/she] hit [his/her] head and [his/her] left arm and shoulder and that it was hurting really bad. Resident was noted to have a skin tear to left elbow. Resident #5 was sent emergently to the local emergency department where he/she spent several hours and was found to have a distal radius and ulnar styloid fracture of the left forearm (a break of both bones in the forearm) requiring splinting.
Resident #5's care plan was reviewed and noted to contain the nursing diagnosis Fall risk related to unsteady gait, chronic obstructive pulmonary disease, peripheral vascular disease [limited blood flow to extremities], hearing impaired, glaucoma, wears [bilateral ] hearing aids. This care plan entry was created 4/20/23 with a review date of 5/19/23. Beneath the entry is an additional notation stating [Resident #5]'s family reports that [he/she] is legally blind and has an unsteady gait. The Interventions included and intended to be a response to the risk of falls, include three that are written notices intended to be read and understood, which, based on the MDS visual assessment as well as the family report of legal blindness are unrealistic and proved to be ineffective: 1. Place a sign on walker to remind me to call for assistance before I ambulate by myself. 2. Put stop sign on oxygen tank to help deter turning oxygen settings. 3. Visual aide in room to remind [patient] to call for assistance before ambulating. There was no evidence that the Resident's ability to read the signs was assessed. There is also an intervention of every 15-minute safety checks to ensure {resident name} is safe and ask if he/she is needing anything.
On 10/10/23 at approximately 3:45 PM the Licensed Practical Nurse (LPN) MDS coordinator provided a fall assessment for Resident #5 with a completion date of 5/4/23 and a next due date of 8/2/23, this assessment had a total score of 10 labeled HIGH. The LPN confirmed no other fall assessments had been done. The facility policy entitled Falls and Fall Risk, Managing with a revision date of March 2018 was reviewed. There is no reference to the fall risk assessment or how to use the scores determined by the assessment.
On 10/11/23 at approximately 10:30 AM the Director of Nursing (DON) was interviewed regarding Resident #5 and their care plan interventions related to falls. The DON stated he/she had updated the care plan following the most recent fall by adding visual aide in room to remind pt to call for assistance before ambulating, and will refer to PT [physical therapy] for evaluation related to frequent falls and generalized weakness [status post] recent illness. The DON was not certain if a therapy evaluation had been completed and the care plan did not reflect any new interventions from a physical therapy screen or assessment. The DON also stated he/she was unaware that Resident #5 had impaired vision and had missed noticing that on the care plan, and did not know if Resident #5 was on 15-minute checks.
Following this conversation , the surveyor and DON went to the medication nurse to request the 15-minute check sheet to verify the 15-minute checks were being completed per the care plan. The nurse advised there were no residents on 15-minute checks. The DON was able to locate check sheets that had been done every 30 minutes (although the care plan called for 15-minute checks) between 9/10/23-9/28/23 and appeared to have been discontinued without any explanation prior to the 10/4/23 fall with injury resulting.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0699
(Tag F0699)
A resident was harmed · This affected 1 resident
Based on resident representative and staff interviews and record review, the facility failed to create and implement an individualized person-centered plan to render trauma-informed care to a resident...
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Based on resident representative and staff interviews and record review, the facility failed to create and implement an individualized person-centered plan to render trauma-informed care to a resident with a personal history of trauma, related to witnessing a relative drown, for 1 of 20 residents sampled (Resident #30). Findings include:
Record review reveals that Resident #30 was admitted in April 2021 with diagnoses including Alzheimer's disease, muscle weakness, and major depressive disorder. On 10/9/23 at approximately 12:20 PM, Resident #30's Representative noted that at times Resident #30 does not appear to have been bathed and at other times they receive reports that Resident #30 has assaultive behaviors that occur during bathing. Resident #30's Representative detailed a past traumatic event during which Resident #30 was witness to a family member drowning and has had a terror of water ever since. Per the Representative, this traumatic event was discussed with the Social Services Director during a care planning meeting. During a review of the care plan for Resident #30 an entry for activities of daily living is noted to include the requirement of 1-2 staff for bathing assistance however there is no mention of triggers related to water-induced trauma, strategies, approaches, or staff response to resultant behaviors. A review of the bathing record for Resident #30 between 9/1-10/9/23 reveals during the 6 week period Resident #30 received 3 tub baths.
Per interview on 10/9/23 at 10:37 AM, the Social Services Director confirmed that s/he was made aware of Resident #30's history of trauma during an 8/31/23 a care planning meeting but was unsure of how that could be incorporated into the care plan.
On 10/10/23 at 11:30 AM the Director of Nursing confirmed that resident-centered individualized information related to trauma-informed care was not in the care plan.
On 10/10/23 at 1:30 PM a Licensed Nursing Assistant (LNA) described the bathing process for Resident #30 as horrible and stated that when they lower the resident into the water [s/he] screams and hits, [s/he] screams like you're killing [him/her], and I don't know if it's the water or what it is but we have to do it we can't have [him/her] stinking.
Resident #30 was interviewed by the surveyor on 10/10/23 at approximately noon, Resident #30 demonstrated cognitive impairment and appeared unable to comprehend questions therefore was unable to describe any potential psycho-social outcomes related to his/her bathing experience. However, employing the reasonable person concept which allows determination of the severity of the psycho-social outcome or potential outcome the deficiency may have on a reasonable person in the resident's position it is clear that if one had a terror of water as Resident #30 has the experience of being lowered into the water despite screaming like one is being killed represents psychosocial harm.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on staff Interview and record review the facility failed to follow Pharmacist's recommendations concerning a stop date for psychotropic medication for 1 of 5 residents sampled (Resident #25). Fi...
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Based on staff Interview and record review the facility failed to follow Pharmacist's recommendations concerning a stop date for psychotropic medication for 1 of 5 residents sampled (Resident #25). Findings include:
Per record review Resident #25 has diagnoses that include Major depressive disorder and nightmares. Review of Resident #25's physician orders reveals a current order for Clonazepam 0.5 milligrams (mg) by mouth every 6 hours as needed (PRN) for agitation. (Clonazepam is used as a treatment for panic attacks, insomnia, and symptoms related to chronic anxiety and anxiety disorders). A Consultant Pharmacist Medication Regime review dated 9/1/2023 to 9/17/2023 states attn [attention] Nursing this consult is repeated from July and August as I cannot locate that it had been addressed in response to my consult from last month. The physician authorized to extend the following order by 90 days; Clonazepam 0.5 mg every 6 hours as needed, please update the order in the Electronic Medication Record (EMR) to have an end date of 9/25/23.
During interview on 10/10/2023 at 12:12 p.m. the Minimum Data Set (MDS) Coordinator confirmed that there is no documentation that the as-needed Clonazepam has had a stop date added to the order. He/she also confirms that there should be a stop date for this as-needed medication and the Consultant Pharmacist Medication Regime Review was not followed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike env...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for the residents of the facility.
Findings include:
A tour of the facility was conducted with the Maintenance Director on 10/11/23 at 8:57 AM.
Observations of resident environment issues were confirmed by the Maintenance Director during the facility tour and included:
room [ROOM NUMBER] & 9- shared bathroom- wood baseboard molding with peeling paint, vinyl wall covering with chipped and curling edges. Areas of the door frame with bare wood or have peeling paint, and there are insulated wires without conduit running above the toilet around the door frame. The bathroom mirror has multiple chipped and bare edges.
room [ROOM NUMBER]- the baseboard radiator beneath the window has bent and detached front panels, exposing bare metal radiator fins.
room [ROOM NUMBER]- The room's baseboard radiator against the far wall is bent, paint scratched off, and missing the inner panel. There are 3 bare pieces of wood screwed into the wall above the radiator holding a wheel of the resident's bed in place. During the 3 days of the survey, the only chair in the resident room had an overturned table, legs upward, placed on the chair's seat cushion.
room [ROOM NUMBER]- The room's baseboard radiator beneath the window has bent and detached front panels, exposing the bare metal radiator fins. The windowsill has peeling paint and exposed chipped wood.
room [ROOM NUMBER]- 2 areas of the room's baseboard radiator have bent and detached front panels, exposing the bare metal radiator fins.
Per interview with staff on the second floor, 5 of 9 rooms on the second floor share a single communal bathroom.
Observations of the communal bathroom on the second floor, conducted with the Maintenance Director on 10/11/23, confirmed the vinyl baseboard molding behind the toilet was detached from the wall and/or resting on the floor. There was no baseboard molding between the wall and the floor on the left side wall next to the sink, and the floor tiles next to the sink had a large brown stain. An area of floor behind the communal tub contained multiple layers of dust and dirt, along with a dirty cloth wipe. The Maintenance Director confirmed that it appeared not to have been cleaned for an extended period of time.
Metal grab bars located on either side of the toilet were missing bolts that attached them to the wall. When weight was put on the grab bars, the vinyl wall covering flexed outward from the wall. The Maintenance Director stated that the bolts were missing because there was no wall stud behind the vinyl covering to secure and attach them to.
Observations of resident rooms on the facility's first floor, conducted with the Maintenance Director on 10/11/23, included:
room [ROOM NUMBER]- The room's baseboard radiator is missing the middle panel.
room [ROOM NUMBER]- both windowsills, including one over the resident's bed, have cracked and flaking paint.
room [ROOM NUMBER]- windowsill with cracked and flaking paint.
A ceiling fan within reach of residents on the first-floor hallway has an exposed and empty light bulb socket. The Maintenance Director stated that the fan 'should be removed'.
Per interview with the facility's Maintenance Director on 10/11/23 at 8:57 AM, the Director stated that anybody can make a maintenance request regarding resident rooms, conditions, or equipment in the building. The Director reported that request forms are available at the nurse's stations and are collected daily. The Director stated that Maintenance conducts room checks weekly, and that radiator issues happen all the time. The Director confirmed there were no Maintenance requests regarding any of the observed conditions listed above, Maintenance had not identified the issues, and that there were no repairs scheduled to address the issues. The Maintenance Director stated, I am waiting for someone to tell me to do it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
2. Per record review, Resident #15's medical diagnosis includes Major Depression. Review of Resident #15's physician orders reveals that Resident #15 is currently receiving the following psychotropic ...
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2. Per record review, Resident #15's medical diagnosis includes Major Depression. Review of Resident #15's physician orders reveals that Resident #15 is currently receiving the following psychotropic medications; Abilify (Abilify is an antipsychotic medication. that works by changing the actions of chemicals in the brain. It is used to treat psychotic conditions including schizophrenia and bipolar disorder), Bupropion (Bupropion is a psychotropic medication used to treat depression) and Fluoxetine (Fluoxetine is a psychotropic medication used to treat depression).
Review of Resident #15's care plan reveals that there is no care plan in place for psychotropic medications.
During an interview on 10/11/23 at 10:59 A.M. the Minimum Data Set Coordinator (MDS) Confirmed that the care plan is not in place for psychotropic medications.
Based on interview and record review the facility failed to develop a comprehensive care plan that is individualized and meets the needs identified for each resident based on the diagnosis and medications prescribed for 2 of 20 residents sampled (Resident's #13& #15). Findings include:
1. Resident #13 was admitted to the facility in April 2023 with diagnoses including acute respiratory failure with hypoxia (deprivation of adequate oxygen supply), chronic heart failure, major depressive disorder, and diabetes type II. Medications include insulin orders: Novolog FlexPen 100 unit/milliliter solution use sliding scale three times per day (sliding scale dose is based on the results of current blood sugar level) and Lantus SoloStar 100 units/milliliter inject 40 units.
A review of the resident care plan reveals the diagnosis of diabetes, and the use of insulin is not included as a focus area. Diabetes and the use of insulin can result in unstable blood sugar levels that may cause hypoglycemia (low blood sugar) or hyperglycemia (elevated blood sugar) both of which present with signs and symptoms that should be monitored for. These may include extreme thirst, confusion, drowsiness, or even coma in the case of hypoglycemia and headache, confusion, and racing pulse in the case of hyperglycemia. If noted these symptoms require a prompt response which should be delineated in the care plan.
On 10/10/23 at 2 PM the Director of Nursing confirmed that diabetes and the use of insulin were not included in the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
2. Per interview on 10/09/2023 at 12:48 p.m., Resident #25 reveals that s/he has not been invited to a care plan meeting and does not know what a care plan meeting is. Per record review, there is no d...
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2. Per interview on 10/09/2023 at 12:48 p.m., Resident #25 reveals that s/he has not been invited to a care plan meeting and does not know what a care plan meeting is. Per record review, there is no documentation to support that Resident #25 had been invited to or attended a care plan meeting. There is also no documentation that supports that Resident #25's participation is determined not practicable. Per physician progress note of 09/26/23 resident is oriented x 2 to person and place.
Per review of the facility policy titled Interdisciplinary Care Plan Conference policy #Q3 section Purpose /Policy statement # 4 Residents are invited to participate and if they grant permission, other family members (or the responsible party) are invited and documented in their resident's care plan.
Per the interview on 10/11/2023 at 8:30 a.m. the Social Services Director confirmed that he/she has not documented Resident #25's invitation and/or attendance to care plan meetings.
Based on interview and record review, the facility failed to revise a comprehensive care plan for 2 of 20 Residents sampled (Residents #13 & #25) to include interventions that address Resident #13's impaired vision and request for large print reading material, and invite/educate Resident #25 regarding care plan meetings.
1.Resident #13 was admitted in April 2023 with diagnoses including hypoxia (the deprivation of adequate oxygen supply), chronic heart failure, major depressive disorder, and type 2 diabetes.
During an interview with Resident #13 on 10/9/23 at approximately 9 AM Resident #13 mentioned having requested large-print reading materials but having only rarely received such materials. They stated they enjoyed reading but could not indulge in this pastime due to poor eyesight. A review of section B (hearing, speech, vision) of the Minimum Data Set (a system used to assess each Resident for numerous uses including care planning purposes) dated 7/28/23 notes Resident 13's vision is assessed to be highly impaired- object identification in question but eyes appear to follow objects. Under Activities in the care plan for Resident #13, the goal of I will try to attend at least 1-3 activity sessions a week of my liking. Followed by The activity staff will supply me with a daily newsletter that has a list of the scheduled activity sessions though out the day. The staff may need to remind me of the time of the scheduled activity session. On 10/10/23 at approximately 3:30 PM the Activities Director acknowledged Resident #13 prefers large print reading material and that there is no indication of such in the care plan. When asked how this information would be communicated to other staff they responded just by verbal.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based upon interview and record review, the facility failed to ensure it used the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week for 52 days from April 1st, 2023,...
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Based upon interview and record review, the facility failed to ensure it used the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week for 52 days from April 1st, 2023, to Oct. 1st, 2023.
Findings include:
A review was conducted of the facility's staffing schedules from April 1st, 2023, to Oct. 1st, 2023 regarding nursing care provided to the facility's residents. Review of the staffing schedule for April 2023 revealed 10 days with no RN scheduled [4/3, 4/6, 4/10, 4/14, 4/17, 4/20, 4/24, 4/25, 4/26, 4/27]. May 2023 included 6 days with no RN coverage [5/8, 5/21, 5/22, 5/27, 5/28, 5/29], June 2023 included 3 days [6/10, 6/11, 6/28] and July 2023, 7 days [7/4, 7/5, 7/6, 7/15, 7/16, 7/20, 7/29]. August 2023 documented 15 days without RN coverage, including 5 consecutive days [8/1, 8/5, 8/8, 8/10 thru 8/14, 8/17, 8/18, 8/22, 8/26, 8/27, 8/30, 8/31] and September thru October 1st, 2023, included 11 days with no RN scheduled [9/2, 9/3, 9/8, 9/9, 9/10, 9/12, 9/14, 9/22, 9/23, 9/24, 10/1].
An interview was conducted with the facility's Administrator [ADM] and Director of Nursing [DON] on 10/11/23 at 11:27 AM. The ADM and DON both confirmed that the facility had no Registered Nurse scheduled or present in the building for a minimum of 8 hours daily as required by regulation on the 52 dates listed above.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain medication and/or non-pharmacological interventions fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain medication and/or non-pharmacological interventions for 1of 3 residents in the applicable sample (Resident #1). Findings include:
Per record review, Resident #1 was admitted to the facility on [DATE] for palliative and end-of-life care related to metastatic breast cancer and pneumonia. S/he died on the morning of [DATE]. A review of the physician's orders reveals an order for Morphine 0.2 ml (milliliters) to be given intramuscularly every two hours as needed for pain. A physician's order dated [DATE] indicates a pain screen was to be performed every shift. Per review of a pain screen from [DATE] at 6:33 AM, it showed that the resident's pain was assessed and medication was given accordingly. Upon further review of the the Medication Administration Record (MAR) and nursing documentation there was no evidence that pain medication was administered to Resident #1.
Per review of the facility's internal investigation, a statement provided by a Licensed Practical Nurse (LPN) reflects that on [DATE], the LPN was met at the door by two Licensed Nursing Aides (LNA) who had worked the night before. The LNAs reported concerns regarding the lack of attention and pain medication provided to Resident #1. The LPN states that S/he assessed Resident #1 and found him/her moaning with harsh labored breathing. The LPN reviewed the MAR to determine when Resident #1 was last medicated. There were no entries documented in the MAR and no evidence that Resident #1 had received any medication during the hours of 11:00 PM to 7:00 AM. Written statements provided by the two LNAs who had reported the incident indicate that during the 11:00 PM to 7:00 AM shift on [DATE], they heard Resident #1 moaning, and upon checking on him/her, they noted a painful expression on his/her face. The LNAs requested that the night nurse administer pain medication to Resident #1 several times during the shift.
During the interview on [DATE] at 12:45 PM, the Licensed Practical Nurse (LPN) confirmed that on the morning of [DATE], S/he had assessed Resident #1 and found her/him moaning with harsh labored breathing. Upon review of the MAR, S/he discovered that the nurse who worked on the 11:00 PM to 7:00 AM shift had not administered pain medications to Resident #1.
During the interview on [DATE] at 12:30 PM, the Director of Nursing (DON) confirmed that there is no evidence in the medical record that Resident #1 received pain medication or any interventions consistent with palliative care to manage her/his symptoms between 11:00 PM to 7:00 AM.
Jul 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident's right to be free from physical, verbal, and mental abuse for 2 of 2 sampled residents (Residents #1 and #3). Findings i...
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Based on interview and record review, the facility failed to ensure a resident's right to be free from physical, verbal, and mental abuse for 2 of 2 sampled residents (Residents #1 and #3). Findings include:
1. Per record review, Resident #1, has been residing at the facility since 2017 and has diagnoses to include dementia, parkinsonism, post-traumatic stress disorder, and congestive heart failure. This resident's care plan reveals interventions related to dementia care and behaviors such as frequent and sometimes loud chanting,
Review of an 05/23/23 facility investigation summary report reveals that a licensed nursing assistant (LNA) reported to a nurse downstairs in the facility at approximately 4:55 PM on 05/18/2023 that, ' . a [travel LNA] was working on the upstairs unit . and asked me to help get [Resident #1] into the bathroom so s/he could give [the resident] a bath, so I did. I left the bathroom and [the travel LNA] called me back in as [Resident #1] was sliding out of the chair and s/he needed assistance to get him/her back into the chair. We slid [the resident] back into the chair and lowered the chair down to the lowest position and . [Resident #1] was making a lot of noise and [the travel LNA] told [Resident #1] to shut up and s/he got a face towel and put it in [the resident's] mouth. That is when I went and told the nurse downstairs.
The written statement from the AP reveals s/he admitted ly put his/her hand over Resident #1's mouth and whispered in his/her ear to 'quiet down.' The investigative summary completed by the facility concluded that per the AP's own admission, it is determined that the AP acted in a physically inappropriate manner toward Resident #1 to quiet his chanting and crying. The employee's contract was terminated, and s/he never worked in the facility again after this incident
Per further review of the facility investigative summary and interview with the Director of Nursing (DNS) at 11:00 AM on 07/18/23, s/he states s/he was notified immediately of the incident and went directly to the facility after receiving the phone call to interview staff and report to the required authorities. The DNS asked the alleged perpetrator (AP) to come to the DNS office where the facility Administrator and DNS asked the AP to describe what actions the AP took while attempting to bathe Resident #1. Per the DNS the AP stated s/he was giving the resident a bath and, ' . [the resident] was chanting and crying very loud.' The DNS states s/he, ' . asked if there was anything else that happened . there is an allegation that you put a washcloth in [the resident's] mouth to quiet [him/her] down. [The AP] responded, [the resident] was chanting and crying very loud.' The AP was immediately suspended pending a full investigation.
Psychosocial assessments were completed on 05/18/23 and 05/23/23. The assessments concluded there was no change from this resident's baseline physical or mental status related to this incident. Due to dementia this resident has no recollection of the event at this time, nor did s/he recollect it directly after it occurred per record review. However, to use the reasonable person concept, one would expect a person who has been physically and verbally abused to feel mental anguish.
At 4:30 PM on 07/18/23 the Director of Nursing (DON) and Administrator confirmed Resident #1 suffered physical, mental, and verbal abuse.
2. Review of a facility investigation summary, dated 6/28/23, reveals that on 6/21/23 Resident #4 ran his/her wheelchair into Resident #3, knocking Resident #3 to the floor. Prior to the incident, Resident #3 was in the dining room cleaning up Resident #4's meal while Resident #4 was away from the table. A progress note, dated 6/22/23, stated that upon returning to the table, Resident #4 yelled at Resident #3 'Leave my stuff alone. I told you about messing with my stuff. I am going to run you over.' An incident report, dated 6/21/23, reveals that Resident #3 had 3 red marks across the top of his/her foot upon assessment following the event. A 6/22/23 progress note reveals that when asked about the event, Resident #4 had conveyed that s/he was upset and would 'do it again.'
On 7/18/23 at 4:00 PM, the Unit Supervisor stated that Resident #4 has a history of aggressive behaviors and has had prior altercations with Resident #3. Review of a facility investigation summary dated 5/8/23 reveals that on 5/7/23 Resident #3 was attempting to clean up a spill at Resident #4's table. Resident #4 had become upset that Resident #3 was in his/her personal space and commented that s/he would run over Resident #3 if s/he didn't get out of the way.
An incident report 6/21/23 describes Resident #4's actions on 6/21/23 as intentional during the incident with Resident #3. At approximately 5 PM on 7/18/23, the DON confirmed that Resident #4 was physically abusive with Resident #3 during the events on 6/21/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of an alleged violation of neglect to the state survey and certification agen...
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Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of an alleged violation of neglect to the state survey and certification agency for one applicable resident (Resident #2); and failed to ensure that employees immediately report an injury of unknown source to the facility administrator and state survey and certification agency for one applicable resident (Resident #3). Findings include:
Facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised 9/2022, states: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.
1. A review of a facility investigation, dated 4/17/23, reveals that facility staff reported to the previous Administrator an allegation of neglect in regard to Licensed Nurse #2 not administering pain medications to Resident #2, who was actively dying and suffering. The investigation note reveals that Licensed Nurse #2 was terminated because of this event. There is no evidence that this allegation was reported to the state survey and certification agency.
On 7/18/23 at approximately 5:00 PM, the Administrator and Director of Nursing (DON) confirmed that this event had not been reported to the state survey and certification agency.
2. Per review of Resident #3's medical record, the following 7/3/23 nurse progress was discovered: AM LNA [Licensed Nursing Aide] called nurse to bedside, as resident has a new bruise noted to the left side of his back. Moderate in size and dark purple in color. LNA said she did not previously see this bruise this week. There are no other notes in Resident #3's medical record that reveal this injury was reported to the DON or Administrator, or that this injury was investigated.
On 7/18/23 at approximately 5:00 PM, the DON indicated that s/he was unaware of Resident #3's bruise or any investigation into an injury of unknown origin for Resident #3. On 7/19/23 at 11:23 AM, the DON revealed that the nurse only wrote a progress note about this and this nurse did not report it to his/her supervisor or the DON. S/He confirmed that s/he should have been made aware of this injury.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents received medication in accordance with physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents received medication in accordance with physician orders and facility policy for 5 of 17 sampled residents (Residents #5, #6, #7, #8, and #9). Findings include:
A medication administration audit was performed by the Director of Nursing (DON) for all 17 residents residing on the upstairs unit for 7/14/23 through 7/16/26. The audit revealed that 5 of the 17 residents had a significant number of refusals documented during the 7 AM- 7 PM shift. Review of the nursing schedule reveals that Licensed Practical Nurse (LPN) #1 worked the 7 AM- 7 PM shift on the upstairs unit on 7/14/23, 7/15/23, and 7/16/23. This was confirmed on 7/20/23 at approximately 12:30 PM by the DON.
Review of Resident #5's medication administration records (MAR) between 7/14/23 and 7/16/23 revealed the following medications documented as refused:
7/14/23- 2 doses of divalproex 125 mg sprinkle cap for dementia with behaviors;
7/14/23- 1 dose Quetiapine Fumarate 12.5 mg for dementia with behaviors
7/14/23- 1 dose Spironolact 25mg for edema
7/14/23- 1 dose Montelukast 10 mg for emphysema
7/14/23- 2 doses Pancrease 4200-14200 UNIT with meals for exocrine pancreatic insufficiency
7/14/23- 2 doses Lactase Enzyme 3000 UNIT with meals for disorders of diaphragm
Review of Resident #6's medication administration records (MAR) between 7/14/23 and 7/16/23 revealed the following medications documented as refused:
7/15/23- 1 dose Tamsulosin 0.8 mg for prostate cancer
7/15/23- 1 dose Baclofen 10 mg for osteoarthritis pain
7/15/23- 1 dose Lisinopril 20 mg for hypertension
7/15/23- 1 dose Acetaminophen extra strength 1000mg for peripheral vascular disease pain
7/15/23- 1 dose Citalopram 10 mg for depression
7/15/23- 1 dose Quetiapine Fumarate 50 mg for dementia with behaviors
7/15/23- 1 dose Calcium 600 mg and D 200IU for supplement
7/15/23- 1 dose Timolol maleate solution 0.25% for glaucoma
7/15/23- 1 dose Polyth Glyc [NAME] 17 mg for constipation
7/16/23- 1 dose Tamsulosin 0.8 mg for prostate cancer
7/16/23- 1 dose Tamsulosin 0.8 mg for prostate cancer
7/16/23- 1 dose Lisinopril 20 mg for hypertension
7/16/23- 1 dose Acetaminophen extra strength 1000mg for peripheral vascular
7/16/23- 1 dose Citalopram 10 mg for depression
7/16/23- 1 dose Quetiapine Fumarate 50 mg for dementia with behaviors
7/16/23- 1 dose Calcium 600 mg and D 200IU for supplement
7/16/23- 1 dose Timolol maleate solution 0.25% for glaucoma
7/16/23- 1 dose Polyth Glyc [NAME] 17 mg for constipation
Review of Resident #7's medication administration records (MAR) between 7/14/23 and 7/16/23 revealed the following medications documented as refused:
7/15/23- 1 does Senna 8.6 mg for constipation
7/15/23- 2 doses quetiapine 12.5 mg for dementia with agitation
7/15/23- 2 doses Acetaminophen extra strength 500 mg for polyneuropathy pain
7/15/23- 1 drop in each eye- artificial tears solution
7/15/23- 1 dose gabapentin 100 mg for neuropathic pain
7/15/23- 2 doses furosemide 20 mg for polyneuropathy
Review of Resident #8's medication administration records (MAR) between 7/14/23 and 7/16/23 revealed the following medications documented as refused:
7/15/23- 1 does metoprol 25 mg for high blood pressure
7/15/23- 1 dose omeprazole 20 mg for gastro-intestinal protection
7/15/23- 1 dose quetiapine 150 mg extended release for schizoaffective disorder
7/15/23- 1 dose glipizide extended release for diabetes
7/15/23- 1 dose multi vitamin with minerals for supplement
7/15/23- 1 dose amlodipine 5 mg for hypertension
7/15/23- 1 dose aspirin 81 mg for heart health
7/15/23- 1 dose probiotic for antibiotic use
7/15/23- 1 dose novolog flex pen (sliding scale based on blood sugar) for diabetes
7/15/23- 2 doses furosemide 40 mg for heart failure
7/15/23- 1 dose Levemir flex pen 60 units for diabetes
7/15/23- 1 dose prednisone 10 mg for skin blisters
7/16/23- 1 dose metoprol 25 mg for high blood pressure
7/16/23- 1 dose omeprazole 20 mg for gastro-intestinal protection
7/16/23- 1 dose quetiapine 150 mg extended release for schizoaffective disorder
7/16/23- 1 dose glipizide extended release for diabetes
7/16/23- 1 dose multi vitamin with minerals for supplement
7/16/23- 1 dose amlodipine 5 mg for hypertension
7/16/23- 1 dose aspirin 81 mg for heart health
7/16/23- 1 dose probiotic for antibiotic use
7/16/23- 1 dose novolog flex pen (sliding scale based on blood sugar) for diabetes
7/16/23- 1 dose furosemide 40 mg for heart failure
7/16/23- 1 dose Levemir flex pen 60 units for diabetes
7/16/23- 1 dose prednisone 10 mg for skin blisters
Review of Resident #9's medication administration records (MAR) between 7/14/23 and 7/16/23 revealed the following medications documented as refused:
7/14/23- 1 dose furosemide 40 mg for hypertension
7/14/23- 1 dose trazodone 50 mg for chronic post-traumatic stress disorder
7/21/23 at 1:20 PM, the DON stated that there was no evidence in Resident #5, #6, #7, #9, or #9's medical record that additional attempts were made for medication administration, a nursing supervisor was notified of the residents' refusal, or that the provider was notified of their medication refusal. S/He stated LPN #1 usually works downstairs because s/he doesn't work well with residents that have behaviors and the upstairs unit has a lot of residents with behaviors. S/He confirmed that the above medications documented as refused on the MAR by LPN #1. S/He stated that there should have been documentation of the refusal in the nursing notes, more than just marking it as refused on the MAR, and the provider should have been notified of the refusals.
Apr 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on staff interview and record review, the facility failed to ensure each resident was free from neglect related to medication administration for 10 applicable residents (Residents #1-10). Findin...
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Based on staff interview and record review, the facility failed to ensure each resident was free from neglect related to medication administration for 10 applicable residents (Residents #1-10). Findings include:
Per review of the facility's investigation report for a facility reported event, and confirmed by interview on 4/24/2023 at 11:49 AM, Licensed Practical Nurse (LPN) #1 reports that many medications on the upstairs unit had not been removed from their cycle fill cards [medication cards delivered on a routine cycle] over the weekend. S/He explained that the facility has routine medications delivered on a monthly cycle and all new medications cards were changed over on 4/7/2023. On 4/10/2023, LPN #1 came in for their shift after being off for 4/8/2023 and 4/9/2023 and discovered that the expected number of pills had not been removed from the medication cards over the weekend for many medication cards. This concern was reported to facility leadership immediately.
The facility investigation reveals LPN #2, who had previously been investigated by the facility in February 2023 for unsubstantiated allegations of neglect related to medication administration, was the day shift nurse for the second-floor unit on 4/8/2023 and 4/9/2023. Medication administration records (MAR) and medication cards were reviewed for all second-floor residents by the Assistant Director of Nursing (ADON). This audit revealed the following medications were not administered to Residents #1-10 sometime between 4/8/23 and 4/9/23, serving as evidence of neglect:
Resident #1: Spironolactone, Montelukast, and Depakote
Resident #2: Letrozole and Metoprolol
Resident #3: Lisinopril, Famotidine, and Levothyroxine
Resident #4: Isosorbide, Aricept, Lisinopril, Metoprolol
Resident #5: Glipizide, Quetiapine, Prednisone, Amlodipine, Metoprolol
Resident #6: Quetiapine
Resident #7: Baclofen, Quetiapine, Trazodone
Resident #8 Benztropine, Latuda, Carafate, Risperidone
Resident #9: Sertraline
Resident #10: Lisinopril and Folic Acid
On 4/24/2023 at 11:24 AM, the ADON explained that, per physician's orders and the MAR, the above medications were to be administered during the day shift and were documented as administered by LPN #2 on 4/8/23 and 4/9/2023. S/He confirmed that the audit revealed that the above medications were not administered to Residents #1-#10, even though they were signed off as administered.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Agency as requi...
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Based on staff interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Agency as required for 1 applicable resident (Resident #2). Findings include:
Per record review, facility documentation and staff interviews, a Licensed Practical Nurse (LPN) was accused of restraining a resident to a chair using a bedsheet on 1/24/2023. The facility conducted an investigation that included speaking with witnesses and the accused but was unable to substantiate the allegation, but the LPN was terminated anyway. The facility failed to make a report to the State Agency or Adult Protective Services (APS) as required, and there is no record of a notification being made to the resident's legal guardian and/or representative.
Per an interview on 2/7/2023 at approximately 12:38pm with the Acting Director of Nursing confirmed that s/he did not make a report because s/he was unable to substantiate the allegation.
Jan 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure 1 applicable resident ( Resident # 1) was free from ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure 1 applicable resident ( Resident # 1) was free from physical abuse. Findings include:
On 1/3/23, Resident # 1 initiated a physical altercation with Resident # 2, causing physical harm. Residents # 1 and 2 are roommates. Previously, on 9/10/22, an altercation occured between Residents # 1 and 2. A 9/10/22 nurses note stated that Resident # 1 had hit, punched and kicked Resident # 2. The Residents continued to live in the same room until 1/3/23. On 1/3/23, Resident # 1 was found by staff standing over Resident # 2's bed after staff heard screaming from the room. A nurses note dated 1/3/23 stated that Resident # 2 appeared to have a scratch on the left side of his face, above his lip that was bleeding and there was also red markings on the resident's neck. Resident #2 stated that Resident # 1 was hitting him in the face . On 1/4/23, Resident # 2 decided to press charges on Resident # 1 regarding the altercation that took place on 01/03/2023. Resident # 1 was issued a citation for simple assault by [NAME] State Police on that date.
The above was confirmed by the Director of Clinical Services on 1/10/23 at 11:27 AM.
Oct 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure that its medication error rate was no greater than 5% during a medication administration observation, with the errors id...
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Based on observation, interview and record review the facility failed to ensure that its medication error rate was no greater than 5% during a medication administration observation, with the errors identified for Resident #2. The total error rate for all observations was calculated at 7.41%. The findings include the following:
1. During a medication pass administration observation on 10/4/22 at 8:20 AM with a Registered Nurse (RN), s/he was observed to administer (7) seven oral medications and (1) one inhaled medication to resident #2. Nurse surveyor reconciled the Medication Administration Record (MAR) with the physicans orders and identified that the Advair Inhaler was ordered to be followed with a mouth rinse. It was identified that the Advair inhaler was administered without the mouth rinse. At 10/04/22 at 9:15 AM the RN confirmed that the mouth rinse should have been administered.
2. During the same medication pass, the RN administered Senna 8.6mg, a laxitive, by mouth to resident number #2. Nurse Surveyor reconciled the MAR with the physican's orders. It was identified during reconciliation that the physician order instructed to a give stool sofener with laxative. The RN failed to give the correct ordered medication. 10/04/22 at 9:15 the RN confirmed that the medication administered was the incorrect medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help preve...
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Based on observation and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include:
1. Per observation on 10/04/22 at 11:35 AM, a small fan attached to the upstairs med cart is heavily soiled with loose dust particles. The fan is operating and blows directly over the top of the med cart where medications are poured. The observation was confirmed by the Director of Nurses at time of the observation.
2. During a medication pass administration observation on 10/4/22 at 8:20 AM with a Registered Nurse (RN). S/he was observed to dispense a medication identified as Pregabalin (Lyrica), a medication prescribed to treat pain caused by nerve damage. This medication is a narcotic and must be stored behind double locks. When the RN dispensed the medication, it fell to the floor. The RN picked the medication up off the floor with a tissue, rolled the medication around in the tissue and placed the medication into a medication cup and administered it to Resident #10, with his other medications. The RN should have destroyed the medication witnessed by another licensed nurse and dispensed a new pill as the pill was considered dirty from falling to the floor.
10/04/22 at 9:15 AM the RN confirmed that she should have wasted the medication and dispensed a new one.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure residents have a safe, clean, comfortable and homelike ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure residents have a safe, clean, comfortable and homelike environment. Findings include:
The following observations were made on the second floor unit during the annual recertification survey:
1. In room [ROOM NUMBER], there was missing molding over bed C with exposed broken hard plastic pieces. These plastic pieces were near the head of the resident's bed. Additionally, there is a large section of missing wallpaper over bed B.
2. There is a wooden handrail with peeling paint and splintering wood in the hallway.
3. In room [ROOM NUMBER], there are holes in the tile wall in the bathroom next to the toilet. Additionally, the metal baseboard heater cover is peeled back and partially missing. There is a large section of wallpaper that is missing. On 10/4/22 at 2:50 PM, the Maintenance Director stated that h/she is unaware of the baseboard and tile issues as noted above. H/she is aware of peeling/missing wallpaper in resident rooms.
On 10/04/22 at 03:00 PM, the Director of Clinical Services stated that it is his/her expectation that all needed resident area repairs are done as soon as possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and staff interview, the facility failed to store all drugs and biologicals in locked compartments. Findings include:
Per observation of the second floor treatment cart on 10/3/2...
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Based on observations and staff interview, the facility failed to store all drugs and biologicals in locked compartments. Findings include:
Per observation of the second floor treatment cart on 10/3/22 at 12:07 PM and 10/5/22 at 8:35 AM, staff left the treatment cart unlocked. The unit is primarily a dementia unit and multiple residents were observed wandering in the hallway past the cart. The cart contained the following medications:
Betamethasone 0.05% ointment; Lotrimin spray; Hemorrhoid ointment; Saniclean wipes; Nystatin powder; Hydrogen peroxide 3%; Dermal wound cleanser solution and Mupirocin 2% ointment. The above was confirmed by the Unit Nurse at the time of both observations.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s), $62,020 in fines, Payment denial on record. Review inspection reports carefully.
- • 25 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $62,020 in fines. Extremely high, among the most fined facilities in Vermont. Major compliance failures.
- • Grade F (25/100). Below average facility with significant concerns.
Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Union House Nursing Home's CMS Rating?
CMS assigns Union House Nursing Home an overall rating of 3 out of 5 stars, which is considered average nationally. Within Vermont, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Union House Nursing Home Staffed?
CMS rates Union House Nursing Home's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 74%, which is 28 percentage points above the Vermont average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Union House Nursing Home?
State health inspectors documented 25 deficiencies at Union House Nursing Home during 2022 to 2024. These included: 3 that caused actual resident harm, 21 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Union House Nursing Home?
Union House Nursing Home is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 44 certified beds and approximately 42 residents (about 95% occupancy), it is a smaller facility located in Glover, Vermont.
How Does Union House Nursing Home Compare to Other Vermont Nursing Homes?
Compared to the 100 nursing homes in Vermont, Union House Nursing Home's overall rating (3 stars) is above the state average of 2.8, staff turnover (74%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Union House Nursing Home?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Union House Nursing Home Safe?
Based on CMS inspection data, Union House Nursing Home has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Vermont. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Union House Nursing Home Stick Around?
Staff turnover at Union House Nursing Home is high. At 74%, the facility is 28 percentage points above the Vermont average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Union House Nursing Home Ever Fined?
Union House Nursing Home has been fined $62,020 across 3 penalty actions. This is above the Vermont average of $33,699. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Union House Nursing Home on Any Federal Watch List?
Union House Nursing Home is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.