Union House Nursing Home

In the surveyor’s words

From the most serious findings on record at Union House Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 31, 2026

  Based on observation, interview, and record review, the facility failed to maintain a critical fall-prevention intervention for 1 of 3 sampled residents (Resident #1), who was at high risk due to severe cognitive impairment and repeated falls. Despite a care plan and motion detector alarm system, the device was unplugged and non-operational during the fatal fall. Leadership admitted that an active monitor could have prevented the incident, which resulted in death. Findings include:Per record review, Resident #1 had a Brief Interview for Mental Status (BIMS) of 4 (a cognitive assessment score demonstrating level of impairment), indicating severe cognitive impairment; diagnoses include Alzheimer's disease, dementia, muscle weakness, cognitive communication deficit, anxiety, depression, and… […]

• Actual harm, isolatedF689Oct 11, 2023

  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. […]

• Actual harm, isolatedF699Oct 11, 2023

  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. […]

• Actual harm, isolatedF600Jan 10, 2023

  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. […]

• No harm, potential for more than minimal, widespreadF761Feb 19, 2026

  Based on observations and interviews the facility failed to ensure that drugs and biologicals in the medication storage room were within their expiration date. Findings include: Per observation on 02/10/2026 at 2:23 PM, of the medication storage room the following expired medications were noted: 2 bottles of Naproxen Sodium 220mg 50 caps expired 7/20252 bottles of Caltrate Bone Health Advance 60 tablet expired 12/20252 bottles of Cranberry 450mg 100 tablet expired 12/20252 bottles of Vitamin E 180mg/400IU 100 soft gels expired 12/20253 bottles of Vitamin D 10mcg/400IU 100tabsexpired 5/20254 bottles of CoQ10 100mg 30 soft gels expired 5/20251 bottle of Biotene Dry Mouth Rinse 16oz expired 11/20252 boxes of Antidiarrheal 2mg 24 caps expired 7/20251 box of Antidiarrheal 2mg 12 caps expired… […]