Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Union Nursing during CMS and state inspections, most recent first.
Staff did not follow the abuse prevention policy during an investigation of a sexual abuse allegation involving a resident. The DON failed to suspend the accused CNA, did not notify the physician promptly, and did not collect written statements or questionnaires from staff on the relevant shift. The accused CNA continued to work with residents during the investigation, and key documentation steps outlined in policy were not completed.
Facility staff did not report an allegation of sexual abuse made by a resident to DHSS or local law enforcement within the required two-hour timeframe. The DON, responsible for reporting in the administrator's absence, chose not to report after determining the allegation was not true, despite facility policy requiring immediate notification.
A facility failed to notify residents of available meal alternates and did not provide alternative meals that matched resident preferences for multiple cognitively intact residents. Survey observations found alternates were not posted in the dining room, resident rooms, or weekly menu, and residents reported they were not asked about options and often only knew about PB&J sandwiches or soup. Staff, including the DM, ADON, DON, CNA, and Administrator, acknowledged that residents generally had to ask for alternates and that the options were not consistently displayed or communicated.
Failure to refund discharged residents’ funds within 30 days affected 12 residents whose personal funds remained in the facility operating account. The BOM said refunds should be entered within 14 days of discharge and paid out within 30 days, but the prior BOM did not issue the refunds, and the admin said the facility had been without a BOM for a couple of months.
Incomplete Comprehensive Care Plans: Facility staff failed to develop and implement person-centered care plans that reflected the needs of four residents. One resident had documented behaviors on the POS but no behavior monitoring on the care plan, while others had catheters, an ostomy, and wound treatments documented in the MDS/TAR without corresponding care plan documentation or interventions. The Care Plan Coordinator, an LPN, and the DON all acknowledged that these items should have been included, but the care plans were not updated.
Food was served at unsafe temperatures when a test tray delivered with resident room trays was left at the nurse station and the barbecued pork sandwich and corn measured 99 and 100 degrees F. Resident council minutes also showed repeated complaints about cold food, and the DM and administrator acknowledged that those temperatures were not acceptable.
Staff failed to use PPE during EBP care and did not follow hand hygiene and glove-change practices during wound, catheter, and perineal care. An ADON and RN provided wound and catheter care to residents with wounds and catheters without wearing gowns, and one RN handled supplies with bare hands and continued care with soiled gloves. Two CNAs also performed perineal care without proper hand hygiene or glove changes between dirty and clean tasks, including handling clean items and resident belongings with soiled gloves.
The facility failed to employ a qualified Director of Food and Nutrition Services, as the dietary manager lacked necessary experience and certification. The DM started certification classes with a part-time consultant RD, but these were halted. The administrator acknowledged the DM's lack of qualifications and the absence of full-time certified nutritional staff, affecting all 53 residents.
Facility staff failed to store medications safely, with expired items and unlabeled medications found in two medication carts. Observations revealed expired adhesive tape remover pads, Eucerin cream, and Urea cream, along with Diclofenac gel and Albuterol tubes without labels. Medications like Acetaminophen suppositories were improperly stored. An RN admitted to not checking for expired medications frequently and noted the absence of a policy for this task. In another cart, several inhalers and a Latanoprost solution were opened without an open date, and 27 loose pills were found. A CMT highlighted the lack of a schedule for cleaning expired medications and inconsistent labeling practices.
Facility staff failed to provide continuous oxygen to a resident as ordered and did not store oxygen tubing and nebulizer masks properly, risking respiratory infection. Observations showed oxygen equipment left unbagged and uncovered, with staff unaware of proper procedures. The Director of Nursing acknowledged issues with maintaining bags for equipment storage.
Failure to Implement Abuse Policy During Sexual Abuse Investigation
Penalty
Summary
Facility staff failed to follow their abuse prevention and prohibition policy when investigating an allegation of sexual abuse involving a resident who was cognitively intact and had diagnoses including UTI, fractures, and multiple trauma. The Director of Nursing (DON) did not suspend the Certified Nurse Aide (CNA) accused of abuse, allowing the CNA to continue working and have contact with residents during the investigation. The investigation report lacked documentation of suspension, physician notification, and did not include completed questionnaires or written statements from staff who worked the relevant shift. Interviews revealed that staff who were present during the alleged incident were not asked to complete questionnaires or written statements, and the accused CNA was not informed of the allegation or suspension. The resident's physician was not notified of the allegation until several days after the incident, despite being present in the facility earlier. The administrator confirmed that the DON was responsible for suspending the CNA, notifying the physician, and ensuring all relevant staff were interviewed or provided statements, none of which were completed as required by policy.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident to both the Department of Health and Senior Services (DHSS) and local law enforcement within the required two-hour timeframe. According to the facility's Abuse, Prevention and Prohibition policy, any staff member made aware of abuse allegations is required to report the incident to the mandated state agency and law enforcement within two hours if the allegation involves abuse or results in serious bodily injury. The incident involved a resident who was assessed as cognitively intact and had diagnoses including urinary tract infection, fractures, and multiple trauma. The resident reported to staff and family that they had been sexually abused by a male aide the previous night. The Director of Nursing (DON) documented the resident's report but did not notify DHSS or law enforcement, as required by policy. The DON stated that after speaking with the resident and family, they determined the allegation was not true and therefore did not proceed with the mandated reporting. The facility's records and the DHSS complaint database confirmed that no report was made within the required timeframe. The administrator confirmed that in their absence, the DON was responsible for reporting such allegations, but was unsure why the reporting did not occur.
Failure to Inform Residents of Meal Alternates
Penalty
Summary
The facility failed to notify residents of available alternate food options and failed to provide alternative meals that accommodated resident preferences for 8 of 13 sampled residents. The facility policy stated alternates shall be available for all meals for residents who dislike menu items, with an alternate for breakfast entrees and for lunch and dinner entrees and vegetables. Resident council minutes from July and August 2025 documented repeated complaints about running out of food alternates and having only limited choices such as peanut butter and jelly sandwiches. Observations during the survey showed the available food alternates were not displayed in the dining room, resident rooms, or on the weekly menu. Several cognitively intact residents reported they did not know what alternate options were available, said staff did not ask them about alternates, and stated they often had no choice beyond what was served. One resident said if the meal was not liked, he/she would return to the room and not eat; another said the only option known was a peanut butter and jelly sandwich; another said a requested alternate was not delivered and the resident did not eat that meal. Staff interviews confirmed that alternate options included items such as leftovers, peanut butter and jelly sandwiches, soup, grilled cheese, ham sandwiches, and cereal, but staff said residents had to ask for them and staff did not routinely ask residents if they wanted an alternate. The Dietary Manager, ADON, DON, CNA, and Administrator all acknowledged that alternate choices were not posted or were not known to be posted, and that residents who did not come to the dining room might not know what options existed. Residents who ate in their rooms also reported they were not informed of available alternatives.
Failure to Refund Discharged Residents’ Funds Timely
Penalty
Summary
Facility staff failed to refund resident funds within 30 days of discharge for 12 discharged residents whose personal funds remained in the facility operating account. Review of the facility’s Accounts Receivable Report dated 08/26/25 showed balances held for Residents #62 through #73, with amounts ranging from $108.00 to $15,576.00 and discharge dates ranging from 12/24/23 to 07/27/25, for a total of $35,475.60. During interview, the corporate BOM stated the Accounts Receivable Report should be reviewed monthly, refunds should be entered within 14 days of a resident discharging and not returning, and discharged residents should be paid out within 30 days of discharge, but was unsure why the prior BOM did not issue the refunds. The administrator stated the facility had not had a BOM for a couple of months and was not sure why the prior BOM did not issue the refunds within 30 days.
Incomplete Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive person-centered care plans that reflected the care needs of four sampled residents. Review of the facility’s RAI policy showed the facility was to adhere to CMS regulations for accurate MDS coding and comprehensive care plan development. For one resident, the admission MDS showed the resident was cognitively intact, not assessed for mood, and had no behaviors, but the physician order sheet directed staff to monitor anxiety, agitation, delusions, hallucinations, psychosis, and aggression; the care plan did not include direction for documenting or monitoring behaviors. For another resident, the admission MDS showed severe cognitive impairment, an indwelling catheter, and risk for pressure ulcers/injuries, but the care plan did not document the catheter. For a third resident, the annual MDS showed the resident was cognitively intact, had an ostomy, and was at risk for pressure ulcers/injuries, but the care plan did not document or include interventions for the ostomy. For the fourth resident, the admission MDS showed the resident was cognitively intact, at risk for pressure ulcers/injuries, and had a catheter, while the TAR showed wound treatments for the left great toe, left second toe, and left medial foot; the care plan did not contain documentation of the catheter or wound. During interviews, the Care Plan Coordinator stated he/she was responsible for comprehensive care plans, and an LPN stated the EMR automatically triggered a care plan from the MDS and that he/she did not look at the care plan afterward to adjust anything. The LPN stated behaviors, ostomies, and catheters should be care planned but did not know why they were not included. The DON stated catheter, ostomy, and behavior information should be on care plans and was not aware the care plans were not updated with this information.
Food Served at Unsafe Temperatures
Penalty
Summary
Prepared food items were not maintained at a safe and appetizing temperature when served to residents who ate in their rooms. The facility’s Assistance with Meals policy, revised July 2017, directed staff to hold foods at 136 degrees or above until served, but it did not include guidance on food temperatures upon delivery to residents. Resident council meeting minutes showed repeated complaints about cold food, including cold veggies, cold coffee, raw breakfast meats, cold plates, and food. On 08/26/25, observation showed a service cart next to the steam table with a large stack of plates being used for the noon meal, and the Dietary Manager removed plates from a plate warmer and placed them on the service cart when the stack was depleted. Later that day, a test tray delivered with four resident room trays was left at the nurse station. When the tray was checked, the barbecued pork sandwich measured 99 degrees F and the corn measured 100 degrees F. The DM stated food should be served at 140 or higher and that 100 degrees would not be acceptable, and the administrator stated hot food should be served at 130 to 135 degrees and that 99 or 100 degrees was not acceptable.
Failure to Use PPE and Perform Hand Hygiene During Resident Care
Penalty
Summary
Facility staff failed to use PPE during care for residents on enhanced barrier precautions (EBP). Resident #33 had moderate cognitive impairment, was at risk for pressure injuries, and had an open lesion and a catheter. During wound care, the Assistant Director of Nursing entered the room and provided wound care without putting on a gown, even though the resident was on EBP for wounds and a catheter. The ADON later stated the resident was on EBP and that staff should use PPE with residents on EBP, and acknowledged that the gown was not worn because it was forgotten. Resident #55 was assessed as cognitively intact, at risk for pressure injuries, and had a catheter. During catheter care in the shower room, RN A handled gauze with bare hands, then applied gloves and continued care with the same gloves while adjusting the resident’s shirt and cleansing the catheter tube. During wound care for the same resident, RN A removed the resident’s sock with bare hands, did not perform hand hygiene before putting on gloves, removed the wound bandage, and cleansed the wound with the same soiled gloves. RN A did not wear a gown during either task and stated the resident was on EBP and that gown and glove use were required for direct care. Staff also failed to perform appropriate hand hygiene and glove changes during perineal care. For Resident #29, who was dependent for toileting and bathing and was always incontinent of bowel and bladder, CNA E transferred the resident to bed, did not wash or sanitize hands before putting on gloves, removed a urine-soaked brief, performed perineal care, placed a clean brief, and then handled the resident’s glasses and patted the resident on the head with soiled gloves before removing gloves and leaving without hand hygiene. For Resident #61, CNA C performed perineal care using the same soiled gloves across multiple tasks, changed only one glove at times, and did not perform hand hygiene when gloves were removed or replaced. The DON and Administrator stated staff are expected to change gloves and perform hand hygiene between clean and dirty tasks, and the DON also stated staff had been educated on perineal care and hand hygiene.
Lack of Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The dietary manager (DM) was hired without prior experience in a nursing facility and lacked the necessary certification or education for the position. The DM had started certification classes with the facility's part-time consultant registered dietitian (RD) but only completed two or three classes before the RD had to stop the classes for unknown reasons. The facility's policies did not include qualifications for the Director of Food and Nutrition Services. The administrator acknowledged that the DM had been serving as the interim DM since the previous DM left, but was not officially appointed until January 2024. Despite efforts to find a qualified DM, the facility had not succeeded in hiring one. The administrator was aware that the DM did not meet the qualifications required for the position, and the facility lacked any certified or clinically qualified nutritional staff employed full-time. This deficiency has the potential to affect all 53 residents in the facility.
Unsafe Medication Storage Practices
Penalty
Summary
Facility staff failed to store medications safely, as evidenced by the presence of expired medications and supplies mixed with current resident medications in two out of four medication carts. Observations revealed that the 200 hall medication cart contained expired items such as adhesive tape remover pads, Eucerin topical cream, and Urea 20 intensive hydrating cream. Additionally, medications like Diclofenac Sodium gel and Albuterol sulfate/Ipratropium Bromide tubes were found without labels, and some medications were stored improperly, such as Acetaminophen suppositories lying loose in a drawer. The RN interviewed admitted to not checking the medication cart frequently enough for expired medications and acknowledged the lack of a policy for this task. The RN also noted that medications should remain in their original packaging until used, which was not the case. Further observations of the 100/300 medication cart showed several inhalers and a Latanoprost solution opened without an open date, along with 27 unidentified loose pills in the drawer. A CMT interviewed stated there was no schedule for cleaning out expired medications and mentioned that staff were supposed to put open dates on eye drops and inhalers, but this was not consistently done. The CMT also noted that prescription creams should have dividers to prevent them from touching each other, and medications should remain in their original boxes to ensure proper identification. The lack of adherence to these practices contributed to the unsafe storage of medications in the facility.
Failure to Provide Continuous Oxygen and Proper Storage of Respiratory Equipment
Penalty
Summary
The facility staff failed to ensure that a resident who required continuous oxygen received it as ordered by the physician. The resident, who had a diagnosis of dementia, asthma, and respiratory failure, was observed multiple times without oxygen, despite physician orders for continuous oxygen at two liters per minute. The resident's care plan did not address the use of oxygen or nebulizer, and staff were observed leaving the resident without oxygen, leading to the resident experiencing shortness of breath and gasping for air. Additionally, the facility staff did not store oxygen tubing and nebulizer masks in a manner to prevent respiratory infection for two residents. Observations showed that oxygen tubing and nasal cannulas were left unbagged and uncovered, often placed on dirty surfaces such as bed sheets or the floor. Staff interviews revealed a lack of knowledge and communication regarding the proper storage of oxygen equipment, with some staff unaware of the need to bag or cover the equipment to prevent contamination. The Director of Nursing acknowledged the absence of bags for oxygen tubing and nebulizer masks in resident rooms and stated that there was a problem with maintaining bags in the rooms. Despite the facility's policies requiring oxygen and nebulizer equipment to be stored in plastic bags, staff consistently failed to comply, increasing the risk of infection for residents who were already vulnerable due to their medical conditions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Union
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Health Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| St Clair Nursing Center | 5.5 mi | ★★★★★ | 1 | 0 |
| Grandview Healthcare Center | 10.1 mi | ★★★★★ | 17 | 0 |
| Pacific Care Center | 11.5 mi | ★★★★★ | 21 | 0 |
| Arbor View Nursing And Rehabilitation | 17.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.