Union House Nursing Home

Inspectors wroteBased on interview and record review the facility failed to ensure that four of four sampled residents (Res.#1, Res.#2, Res.#3, and Res.#4) were free from misappropriation of property related to medication.

Inspectors wrotePer interview and record review, the facility failed to ensure one of four sampled employees received medication administration competency prior to administering medications.

Inspectors wroteBased on observations and interviews the facility failed to ensure that drugs and biologicals in the medication storage room were within their expiration date.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 of 6 Licensed Nursing Assistants (LNA) had completed the mandatory 12 hours of annual training, and 2 of 6 LNAs had completed dementia training.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right to a dignified existence by failing to provide access to the first floor of the building in a manner that provided safety and comfort for 1 applicable resident in the sample (Resident #1).

Inspectors wroteBased on interview and record review the facility failed to provide the Notice of Medicare Non-Coverage at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies were ending for 1 of 3 residents reviewed (Resident #32).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living [ADLs] without assistance receives the proper level of assistance for nail care for 1 of 2 sampled residents (Resident #10).

Inspectors wroteBased on interview and record review the facility failed to provide culturally competent and trauma-informed care by failing to ensure a care plan identified triggers of past trauma and provided interventions for those triggers for 1 applicable resident in the sample (Resident #8).

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 4 residents in the sample, (Resident #1).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).