Union City Care Center
907 East Central Street, Union City, OH 45390 · For profit - Corporation · 43 certified beds · (937) 968-5284 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2020
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.9% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 0.8% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.5% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 6.3% | 30.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.1% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 41.3% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 3.4% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 10.1% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.0% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.75 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 1.80 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2025Q4 — more than 71% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 43 beds and averages 33.4 residents a day — about 78% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.26 on weekdays — 6% thinner on weekends. RN hours go from 0.53 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Fcited before2026-05-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure foods were served and handled in a manner to prevent contamination. This had the potential to affect all 38 residents residing in the facility. The facility census was 38.Findings include:1. Observation on 05/06/26 at 11:40 A.M. revealed Dietary Manager (DM) #244 wore gloves to scoop up pasta shells and green beans. DM #244, while wearing the same gloves she touched serving utensils and plates with, picked up a slice of garlic toast with the gloved hand and put it on the lunch plates. Interview on 05/06/26 at 11:59 A.M. with DM #244 confirmed she should have used kitchen tongs to pick up the bread slices and place on the plate rather than the gloved hands she used to touch serving utensils and plates. 2. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses of acute respiratory failure, generalized muscle weakness, contracture, dysphasia, major depressive disorder,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident representative interview, resident interview, and policy review, the facility failed to ensure quarterly care conferences were conducted. This affected four residents (#3, #7, #9, and #22) out of twelve residents reviewed for care planning. The facility census was 38.Findings include:1. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses including unspecified dementia, repeated falls, cognitive communication deficit, generalized weakness, Type II diabetes, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, required set-up assistance for activities of daily living (ADLs), and touch assistance for transfers. Record review of care plan conferences revealed the facility held a care conference for Resident #7 on 04/30/25. The next documented care conference was on 03/18/26. Interview on 05/05/26 at 1:45 PM with the Director of Nursing (DON)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of resident personal needs accounts and receipts, the facility failed maintain an accurate accounting of resident funds. This affected three (#6, #10, and #8) of three residents reviewed for resident personal funds accounts. The facility census was 38. Findings include:1. Medical record review for Resident #6 revealed an admission dated of 01/09/24 with diagnoses including but not limited to chronic obstructive pulmonary disease with exacerbation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 revealed the resident was assessed with intact cognition and required set up assistance for eating and bed mobility, and moderate assistance for toileting and transfers. Review of the facility's petty cash receipts for Resident #6 revealed a transaction from the resident needs fund, dated 03/13/26 for $5.71. Further review of the receipts revealed the resident's initials and staff initials were of similar handwriting. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and policy review, the facility failed to notify the physician of significant weight loss. This affected one (#20) out of two residents reviewed for nutrition. The facility census was 38.Findings include:Review of the medical record for Resident #20 revealed an admission date of 02/12/19 with medical diagnoses of diabetes mellitus, schizoaffective disorder, dementia with behavioral disturbances, and heart failure.Review of Resident #20's quarterly Minimum Data Set (MDS) assessment, dated 03/25/26, revealed the resident was cognitively intact, required partial/moderate staff assistance with bed mobility and transfers, was dependent upon staff for toilet hygiene, and required set-up assistance with eating. The MDS assessment indicated Resident #20 had a significant weight loss and was not on a physician prescribed weight loss program. Review of Resident #20's physician orders revealed an order dated 09/10/24 for weekly weights and an order dated 12/11/25 for a no added salt, carbohydrate-controlled diet, with regular texture and thin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to complete a discharge summary and a recapitulation of stay upon resident discharge. This affected two (#41 and #44) residents out of three reviewed for discharges. The facility census was 38.Findings include:1. Review of the medical record for Resident #41 revealed an admission date of 05/12/25 with medical diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, delusional disorders, hypertension, and unspecified psychosis. Resident #41 transferred to another nursing facility on 02/03/26. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, revealed the resident had moderate cognitive impairment and was independent with bed mobility, transfers, toileting, and bathing. Review of Resident #41's nursing note dated 01/14/26 at 1:51 P.M. revealed a care conference was held with the resident's Guardian via telephone. The note revealed and update was provided on transfer status,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and policy review, the facility failed to develop comprehensive person-centered care plans to address resident needs. This affected two (#31 and #35) residents out of twelve residents reviewed for care plans. The facility census was 38.Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 08/23/24 with medical diagnoses of chronic obstructive pulmonary disease, hypertension, and major depression.Review of Resident #31's quarterly Minimum Data Set (MDS) assessment, dated 03/05/26, revealed the resident was assessed with severe cognitive impairment, was independent with bed mobility and transfers, required supervision with toilet hygiene, and required partial/moderate staff assistance with bathing. Review of Resident #31's physician orders revealed an order dated 03/27/26 for Zoloft (antidepressant) 50 milligram (mg) one tablet by mouth every evening for depression.Review of Resident #31's care plans revealed no documentation to support the facility developed a comprehensive person-centered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure referrals to specialized medical professionals to address impaired hearing were arranged as recommended. This affected one (#9) of one residents reviewed for hearing loss. The facility census was 38. Findings include:Medical record review for Resident #9 revealed an admission date of 12/02/24 with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes mellitus, epilepsy, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed the resident had intact cognition. Resident #9 was coded with highly impaired hearing without hearing devices and was assessed as requiring set up assistance for eating and toileting, and was independent for bed mobility and transfer. Review of the plan of care for Resident #9 revealed the resident presented with a sensory impairment which may adversely affect…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, fall investigation document review, staff interview, and policy review, the facility failed to complete neurological evaluations for residents following unwitnessed falls. This affected one (#1) resident out of two residents reviewed for accidents. The facility census was 38. Findings include:Review of the medical record for Resident #1 revealed an admission date of 10/08/13 with medical diagnoses of peripheral vascular disease, Alzheimer's disease, and aortic aneurysm. Review of the Resident #1's Minimum Data Set (MDS) assessment, dated 02/24/26, revealed the resident had severely impaired cognition, required substantial/maximum assistance for transfers and bed mobility with no ambulation noted, and was dependent upon staff for toilet hygiene. The MDS assessment indicated Resident #1 sustained a fall with major injury. Review of Resident #1's fall investigation report dated 01/17/26 revealed the resident had an unwitnessed fall and was found on the floor on the side of the bed. The report revealed Resident #1 was unable to recall what happened and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and policy review, the facility failed to ensure collaboration with a hospice provider for development and implementation of a resident's plan of care. This affected one (Resident #35) of one residents reviewed for hospice services. The facility census was 38.Findings include:Review of the medical record for Resident #35 revealed an admission date of 03/06/26 with medical diagnoses of bipolar disease, schizophrenia, dementia, abnormal weight loss, and anxiety. Review of Resident #35's significant change Minimum Data Set (MDS) assessment, dated 04/29/26, the resident was assessed with severe cognitive impairment, required supervision with transfers, bed mobility, and eating, and was dependent upon staff for toilet hygiene. The MDS assessment indicated Resident #35 received hospice services. Review of Resident #35's physician orders revealed an order dated 04/24/26 to refer the resident to hospice. Further review revealed no other hospice orders. Review of Resident #35's nursing note dated 04/23/26 at 10:29 A.M. revealed a care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and medical record review, the facility failed to ensure medications were administered in a manner to prevent contamination. This affected two ( #18 and #32) of three residents observed for medication administration. The facility census was 38.Findings include:1. Medical record review for Resident #18 revealed an admission date of 06/03/24 with diagnoses included but not limited to severe bipolar disorder, schizoaffective disorder, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) assessment for Resident #18 dated 03/13/26 revealed the resident had intact cognition, required set up assistance for eating, and was independent with toileting, transfers, and bed mobility.Review of active physicians orders for Resident #18 revealed an order dated 12/15/24 for cholecalciferol tablet 1000 units with instructions to give one (1) tablet by mouth every day for vitamin supplement; an order dated 07/30/24 for docusate sodium oral capsule 100 milligrams (mg) with instructions to give 1 capsule by mouth daily for constipation; an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2025-12-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report an allegation of misappropriation of resident property. This affected one (Resident #10) of three residents reviewed. The facility census was 36.Findings Include:Review of the closed record for Resident #10 revealed she was admitted initially 08/19/25 with re-entry 10/16/25. She was discharged [DATE]. Her diagnoses included chronic pain, protein-calorie malnutrition, major depressive disorder, rheumatoid arthritis, hypertension, metabolic encephalopathy, anemia, hyperlipidemia and gastro-esophageal reflux disease. Review of her admission Minimum Data Set (MDS) dated [DATE] revealed her Brief Interview of Mental Status (BIMS) score was eight indicating moderate cognitive impairment. She required set-up assistance for eating, moderate assistance for toileting, maximal assistance for bathing, dressing and personal hygiene. Review of her Care Plan dated 08/20/25 revealed she required healthcare monitoring related to opioid use for chronic pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to investigate an allegation of misappropriation. The affected one (Resident #10) of three residents reviewed. The facility census was 36.Findings Include:Review of the closed record for Resident #10 revealed she was admitted initially 08/19/25 with re-entry 10/16/25. She was discharged [DATE]. Her diagnoses included chronic pain, protein-calorie malnutrition, major depressive disorder, rheumatoid arthritis, hypertension, metabolic encephalopathy, anemia, hyperlipidemia and gastro-esophageal reflux disease. Review of her admission Minimum Data Set (MDS) dated [DATE] revealed her Brief Interview of Mental Status (BIMS) score was eight indicating moderate cognitive impairment. She required set-up assistance for eating, moderate assistance for toileting, maximal assistance for bathing, dressing and personal hygiene.Review of her Care Plan dated 08/20/25 revealed she required healthcare monitoring related to opioid use for chronic pain syndrome and refused…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and policy review, the facility failed to properly thaw hamburger meat, failed to ensure dishwasher temperatures achieved proper temperatures, and failed to ensure the sanitizer was working and tested properly. This had the ability to affect all residents at the facility. The facility census was 35. Findings include: 1. Observation on 04/10/23 at 8:37 A.M. revealed an approximately four inch (in) by (x) 24 in packaged tube of hamburger meat lying directly on the bottom of the first compartment of the three compartment sink. The packaged meat was submerged in approximately two inches of cool water, further observation revealed approximately one inch of the burger felt thawed and the middle remained hard. Interview on 04/10/23 at 8:49 A.M. with Dietary Staff (DS) #49 revealed she had put the hamburger in cool water in the sink to thaw at 6:45 A.M. DS #49 verified the water was not running, the burger was not fully submerged and approximately one inch of the perimeter was thawed. Review of the facility policy, Preventing Foodborne Illness-Food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, guardian interview, and policy review, the facility failed to notify a resident's representative when new orders were received. This affected one (Resident #23) reviewed for change in condition. The facility census was 35. Findings include: Medical record review for Resident #23 revealed an admission date of 05/22/17 with diagnoses including dementia without behaviors, chronic obstructive pulmonary disease, malnutrition. emphysema, acute cystitis without hematuria, metabolic encephalopathy, weight loss, bladder dysfunction, hypothyroidism, hyperlipidemia, schizoaffective disorder, major depressive disorder, anorexia, obsessive compulsive disorder, delusional disorders, essential tremor, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] with for Resident #23 revealed intact cognition. Resident #23 required limited assistance for bed mobility, extensive assistance for transfers, limited assistance for eating and extensive assist for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident was free from unnecessary medications when the facility failed to follow through with pharmacy and physician recommendations to decrease a medication dosage. This affected one (Resident #21) of six residents reviewed for unnecessary medications. The facility's census was 35. Findings include: Medical record review for Resident #21 revealed an admission date of 06/06/19 with diagnoses including chronic kidney disease, morbid obesity, congestive heart failure, hypertension, anemia, alcohol induced dementia, malnutrition, osteoarthritis, noncompliance with medical treatment, schizophrenia, major depressive disorder, bariatric surgery status, anxiety, insomnia, repeated falls, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. Resident #21 required extensive assistance for bed mobility from two staff members, extensive assistance for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident was free from unnecessary psychotropic medications when a resident received duplicate medication therapy. This affected one (Resident #27) of six residents reviewed for unnecessary medications. The facility's census was 35. Findings include: Review of medical record for Resident #27 revealed an admission date of 08/20/20. Diagnoses included schizoaffective disorder, noncompliance with medication and medical treatment, extrapyramidal movement disorder, depression, hypertension, bipolar with manic severe with psychotic features, schizophrenia, chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. She required extensive one person assistance for dressing and toileting, limited assistance for bed mobility and personal hygiene, and was independent for transfers and eating.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2020-02-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of a facility policy, review of a facility document, review of a Survey and Certification (S&C) memo and staff interview, the facility failed to develop and implement specific testing protocols through their Legionella Water Management Program. This had the potential to affect all 32 residents residing in the facility. The facility census was 32. Findings include: Review of the facility policy titled Legionella Water Management Program dated 12/17 revealed there were no specific testing protocols identified. Review of the program documentation, completed by the facility, revealed there was no documentation regarding specific testing protocols being completed to prevent Legionella. Review of S&C Memo 17-30 titled Hospitals/Critical Access Hospitals (CAHs)/Nursing Homes (NHs) revealed facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1. Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2020-02-06 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a self-reported incident (SRI), review of witness statements, review of personnel files, staff interviews, and policy review, the facility failed to conduct a thorough investigation following an allegation of verbal abuse and the facility failed to protect residents from potential further abuse when there was an abuse allegation. This affected one resident (#21) of one resident reviewed for abuse. This had the potential to affect 28 of 32 residents except for four (#3, #16, #19 and #34) residents who are independent. The facility census was 32. Findings include: Review of the medical record for Resident #21 revealed an admission date of 10/24/16. Diagnoses included Huntington's disease (progressive breakdown of nerve cells in the brain), anxiety disorder, chronic kidney disease, schizophrenia, major depressive disorder, allergic rhinitis, vitamin D deficiency, difficulty walking, unspecified dementia with behavioral disturbance, muscle weakness, schizoaffective disorder,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2020-02-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, staff interview, and review of a facility policy, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect 31 residents the facility identified as eating from the facility kitchen. (Resident #18 did not eat from the facility kitchen). The facility census was 32. Findings include: During the initial kitchen tour on 02/03/20 at 9:00 A.M. observation revealed a long handled ladle to be present in the plastic storage bin laying atop the sugar. Interview with Dietary Manager #300 on 02/03/20 at 9:00 A.M. at the time of the discovery confirmed the long handled ladle to be present and laying atop the sugar in the dry storage bin. The facility confirmed this had the potential to affect 31 residents who receive meals from the facility kitchen. (Resident #18 did not eat from the facility kitchen). Review of a facility provided policy titled, Food Receiving and Storage with a revision date of 02/2018 revealed dry foods shall be stored in bins and no utensils will be left in containers.
- Potential for harm · D2020-02-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, review of a self-reported incidents (SRI's), review of witness statements, review of personnel files, policy review, the facility failed to ensure a resident was free from staff-to-resident verbal abuse. This affected one (#21) of one resident reviewed for abuse. The facility census was 32. Findings include: Review of the medical record for Resident #21 revealed an admission date of 10/24/16. Diagnoses included Huntington's disease (progressive breakdown of nerve cells in the brain), anxiety disorder, chronic kidney disease, schizophrenia, major depressive disorder, allergic rhinitis, vitamin D deficiency, difficulty walking, unspecified dementia with behavioral disturbance, muscle weakness, schizoaffective disorder, mental disorders and disorders of intestinal carbohydrate absorption. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively impaired and required extensive assistance with bed mobility, transferring, eating,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, review of a self-reported incidents (SRI's) review of witness statements, review of personnel files, the facility failed to timely report an allegation of staff to resident verbal abuse to the state agency. This affected one (#21) of one resident reviewed for abuse. The facility census was 32. Findings include: Review of the medical record for Resident #21 revealed an admission date of 10/24/16. Diagnoses included Huntington's disease (progressive breakdown of nerve cells in the brain), anxiety disorder, chronic kidney disease, schizophrenia, major depressive disorder, allergic rhinitis, vitamin D deficiency, difficulty walking, unspecified dementia with behavioral disturbance, muscle weakness, schizoaffective disorder, mental disorders and disorders of intestinal carbohydrate absorption. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively impaired and required extensive assistance with bed mobility, transferring, eating,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected two (#31 and #2) of nine resident reviewed for accuracy of the assessment. The census was 32. Findings include: 1. Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, hyperlipidemia, bradycardia, anxiety, hypothyroidism, major depressive disorder, congestive heart failure, neuromuscular dysfunction of the bladder, and anemia. Review of the medical record for Resident #31 revealed on 12/02/2019 the resident weight was 176 pounds. Further review of the resident weight documentation revealed on 01/14/20 the resident weight was 164.8 pounds. Review of Resident #31's weights revealed the resident had a significant weight loss of 6.3 percent in one month. Review of the medication administration record dated 01/20 revealed Resident #31 was administered the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, resident and staff interview, and policy review, the facility failed to ensure a resident and other required members of the interdisciplinary team were included in the care planning process. Additionally, the facility failed to complete care conference quarterly. This affected three (#22, #31, and #34) of three residents reviewed for care planning. The census was 32. Findings include: 1. Review of the medical record for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses include neuromuscular dysfunction of the bladder, congestive heart failure, protein calorie malnutrition, anemia, chronic kidney disease, hypothyroidism, osteoarthritis, glaucoma, and kidney failure. Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #22 had moderately impaired cognition. Quarterly MDS assessments were also completed on 12/12/19 and 01/06/20. Review of the medical record for Resident #22 revealed a care planning conference was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview; the facility failed to administered medication as ordered by the physician. This affected one (#31) of five resident reviewed for unnecessary medication. The census was 32. Findings include: Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, hyperlipidemia, bradycardia, anxiety, hypothyroidism, major depressive disorder, congestive heart failure, neuromuscular dysfunction of the bladder, and anemia. Review of the medication administration record (MAR) dated 01/20, revealed Resident #31 was to be administered the medication Carvedilol tablet 3.125 milligram (mg) one tablet by mouth every day and every evening shift to prevent cardiovascular event related to atherosclerotic heart disease. The instructions included parameters to hold the medication if systolic blood pressure (SBP) was less than 90 or pulse was less than 50. Continued review of the MAR revealed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to JAG HEALTHCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.3 | +0.7 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 4 of 5 | 2.4 | +1.6 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 8 homes this chain runs (chain average 3.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GRIFFITHS, JAMES | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 08/01/2013 |
| JAG HEALTHCARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2013 |
| UNION CITY CARE CENTER RE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/03/2016 |
| IDLE, PAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| JUSCHKA, DIRK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2016 |
CMS files one row per role, so the 13 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $349K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 365970. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.