Union House Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Glover, Vermont.
- Location
- 3086 Glover Street, Glover, Vermont 05839
- CMS Provider Number
- 475036
- Inspections on file
- 25
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Union House Nursing Home during CMS and state inspections, most recent first.
A resident with a history of mental health disorders and aggression struck another resident multiple times in the chest after verbally taunting them. The incident was witnessed, reported, and confirmed through investigation, with the aggressor admitting to the physical abuse.
The facility failed to implement a policy for national background checks for LNAs, with only three out of 22 having evidence of such checks. Despite a memo from the Department of Aging and Independent Living requiring these checks, the facility's policy did not reflect this requirement, and the Clinical Lead RN was unaware of the memo.
The facility failed to implement weekly skin checks for three residents at risk for skin integrity issues due to immobility and incontinence. Despite care plans requiring weekly checks, documentation showed significant lapses, with one resident receiving only three checks in 24 weeks, another only one check in 19 weeks, and a third only two checks in 20 weeks. This deficiency was confirmed by an LPN and the DON.
The facility failed to implement adequate fall prevention interventions for two residents at high risk for falls. Despite multiple falls, including incidents resulting in injury, the care plans for these residents were not updated with new interventions as required by facility policy. The Director of Nursing confirmed the lack of adherence to the policy, contributing to the deficiency.
A resident with a hand wound had their soiled gauze dressing improperly handled and reused by an LNA and RN, both of whom were not wearing gloves. The gauze, which had touched the floor, was secured with tape that had been stuck to a chair, violating infection control protocols.
The facility failed to ensure residents' rights to self-determination by keeping all doors locked 24/7, requiring staff intervention for entry and exit. Observations and interviews revealed that residents were dissatisfied with the lack of access to door codes, which restricted their ability to leave and return independently. The DON confirmed that only staff had the code and no policy existed for operating a locked facility.
A resident with Alzheimer's and severe dementia struck another resident with a cane, leading to a physical altercation. Despite interventions in place, the facility failed to prevent the incident, as confirmed by nursing staff. The aggressive behavior of the resident was known, yet the measures were ineffective in ensuring the safety of other residents.
Resident-to-Resident Physical Abuse Due to Unmanaged Aggression
Penalty
Summary
A resident with a history of schizophrenia, major depressive disorder, anxiety disorder, and prior aggression towards others was involved in a physical altercation with another resident. The care plan for this resident identified a potential for behavioral issues and aggression. On the date of the incident, the resident was observed sitting in the dining area when another resident walked by. The aggressive resident began calling the other resident names and then struck them in the chest multiple times. The incident was witnessed and subsequently reported to the state agency as a facility reported incident (FRI). During the facility's investigation, the resident admitted to striking the other resident, citing personal dislike as the reason. The investigation confirmed that physical abuse occurred.
Failure to Implement National Background Checks for LNAs
Penalty
Summary
The facility failed to develop and implement a policy related to national background checks for their employees, specifically Licensed Nursing Assistants (LNAs). A review of the human resource files revealed that only three out of 22 LNAs employed at the facility had evidence of national background checks. This deficiency was confirmed through interviews and record reviews, where the Clinical Lead Registered Nurse (RN) admitted that the facility did not complete national background checks for their employed LNAs. A memo from the Department of Aging and Independent Living, dated October 5, 2022, outlined the requirement for facilities to conduct national criminal background checks prior to employment and annually thereafter. The facility's existing policy, titled Abuse Prevention Program, last revised in December 2016, did not specify the requirement for national background checks. The Clinical Lead RN was unaware of the memo and confirmed that the abuse policy had not been updated to reflect the requirement for national background checks, leading to the deficiency.
Failure to Implement Weekly Skin Checks for Residents
Penalty
Summary
The facility failed to implement care plan interventions for three residents, leading to a deficiency in care. Resident #27 had a care plan initiated to address the risk of skin integrity alteration due to immobility and urinary incontinence, with a goal to remain free from skin alterations. The care plan required weekly skin checks by a licensed nurse, but documentation showed that skin checks were conducted only three times over a 24-week period. Similarly, Resident #39's care plan, initiated to prevent skin integrity issues related to incontinence and immobility, was not followed as required. The resident's records indicated only one skin check in 19 weeks. Resident #294 also had a care plan for skin integrity risks, with only two skin checks documented in 20 weeks. During an interview, both a Licensed Practical Nurse and the Director of Nursing confirmed that the weekly skin checks were not implemented as per the care plans for these residents.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of interventions to prevent falls for two residents. Resident #39, diagnosed with Alzheimer's disease, anxiety disorder, and muscle weakness, was identified as high risk for falls due to disorientation, poor vision, and unsafe attempts to get out of bed and chairs. Despite sustaining five falls in two months, including two consecutive falls and a subsequent fall on December 5, 2024, no new interventions were added to the resident's care plan after the last fall. The facility's policy requires reviewing and updating the care plan after each fall, but this was not adhered to, as confirmed by the Director of Nursing. Similarly, Resident #11, with diagnoses including dementia, schizophrenia, anxiety, depression, and psychosis, was also at risk for falls due to poor safety awareness and unsteadiness. This resident experienced four falls in four months, with the last fall occurring on December 5, 2024, resulting in bruising. Despite the facility's policy to update care plans after falls, no new interventions were added to Resident #11's care plan following the last incident. The Director of Nursing confirmed the lack of adherence to the policy, which contributed to the deficiency in preventing falls.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a resident with a wound on their hand. During an observation, the resident was seen unwrapping a soiled gauze dressing that was visibly contaminated with blood. The gauze was allowed to dangle and come into contact with the floor of the dining area/TV room. A Licensed Nursing Assistant (LNA), who was not wearing gloves, attempted to redress the wound using the same contaminated gauze. Subsequently, a Registered Nurse (RN) also assisted without wearing gloves and secured the gauze with the original tape that had been stuck to the arm of the resident's chair. The Director of Nursing (DON) later confirmed that the soiled dressings should not have been reused.
Facility Fails to Ensure Residents' Right to Self-Determination
Penalty
Summary
The facility failed to honor residents' rights to self-determination and access to the outside world by keeping all doors locked 24/7, requiring staff intervention for entry and exit. This practice was observed during a survey when the front door was locked, and access was only possible by ringing a doorbell to alert staff. A staff member explained that exiting the facility required entering a code on a keypad, which only employees knew. The Director of Nursing (DON) confirmed that residents were not allowed to have the code, and there was no policy or procedure for operating a locked facility or assessing residents' ability to exit independently. Interviews with residents revealed dissatisfaction with the locked doors. One resident, who had been at the facility since 2014, expressed frustration at no longer having the code to exit independently, as they frequently used the porch and left for outside interests. Another resident, who had been at the facility for two years, stated they enjoyed sitting outside but required staff assistance to exit and re-enter the building. The DON confirmed that only staff had the code and could not locate any policy addressing the locked facility.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #1, who has Alzheimer's, severe vascular dementia, and an agitation-induced psychotic disorder, struck Resident #2, who has end-stage Lewy body dementia and parkinsonism, with a cane. This incident occurred in the early morning hours when Resident #2 was standing in the doorway of their room. Despite attempts by witnesses to intervene and redirect, both residents fell to the ground during the altercation. Resident #2 recalled the incident, stating that Resident #1 had hit them multiple times and often caused trouble with others. The facility's records indicate that Resident #1 had a history of aggressive behavior, including hitting staff and other residents with a cane. Interventions in Resident #1's care plan included monitoring while walking the halls and encouraging appropriate use of the cane. However, these measures were ineffective in preventing the incident. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that Resident #1 had struck Resident #2 and staff members during attempts to manage the behavior, indicating a failure to protect residents from physical abuse.
Latest citations in Vermont
The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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