Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Union City Care Center during CMS and state inspections, most recent first.
Food was handled in a way that could contaminate meal service when the DM wore the same gloves to scoop food, touch serving utensils and plates, and place garlic toast on plates instead of using tongs. In addition, a CNA did not perform hand hygiene between serving two residents, including a resident with severe cognitive impairment and dependence for ADLs and another resident with Parkinson's disease and other chronic conditions.
Failure to Conduct Quarterly Care Conferences: The facility did not ensure quarterly care conferences were held for multiple residents with varied medical and cognitive needs, including dementia, CKD, diabetes, COPD, epilepsy, bipolar disorder, blindness, and mobility assistance needs. Record review showed gaps in documented interdisciplinary care conferences despite quarterly MDS assessments, and the DON confirmed missing documentation for several residents. One resident representative reported attending only one conference in the past year, and one resident was unsure what a care conference was.
A facility failed to maintain accurate accounting of resident trust funds for three residents. Petty cash receipts for residents with COPD, dementia with agitation and schizoaffective disorder, and heart disease with neurocognitive disorder showed shopping purchases, but several receipts lacked resident initials or signatures, had handwriting that appeared similar between resident and staff, or had only staff initials. The trust ledgers did not match the receipts, including one transaction posted to the wrong account and other deductions and withdrawals not balanced on the day of the expenditure.
Failure to Notify Physician of Significant Weight Loss: The facility did not notify the physician when a resident had significant weight loss. The resident had diabetes, schizoaffective disorder, dementia with behavioral disturbances, and heart failure, and the chart showed repeated weight loss over time. The RD stated staff are to notify the physician of significant weight loss, and the DON confirmed the physician was not notified and was unaware of the issue.
Failure to Complete Discharge Summary and Recapitulation of Stay: The facility failed to complete discharge summaries and recapitulations of stay for two residents who were discharged. One resident with Alzheimer’s disease, COPD, delusional disorders, HTN, and psychosis transferred to another nursing facility after a guardian care conference, and another resident with AKF, Parkinson’s disease, asthma, dementia, and CHF was discharged home after an appeal was denied and the family was notified of the last covered day. The DON confirmed neither record contained the required discharge documentation.
The facility failed to develop comprehensive person-centered care plans for two residents. One resident with COPD, HTN, major depression, and severe cognitive impairment had a Zoloft order, but the care plan did not address antidepressant monitoring. Another resident with bipolar disease, schizophrenia, dementia, abnormal weight loss, anxiety, severe cognitive impairment, and hospice services had no care plan documenting hospice provider information or the services provided. The DON confirmed the missing care planning.
A resident with highly impaired hearing and no hearing devices was not referred to an audiologist as recommended after an audiology visit noted hearing loss, fetal alcohol syndrome affecting hearing and vision, left ear pain, otitis media, and ear wax impaction. The resident later stated he could not hear from the left ear, had very limited hearing in the right ear, and had not been evaluated for hearing aids; the Administrator verified the audiology referral was never made.
Failure to document neurological evaluations after unwitnessed falls affected one resident with severe cognitive impairment, dependence for transfers and toileting, and diagnoses including Alzheimer's disease and PVD. The resident had two unwitnessed falls and was found on the floor each time; after one fall the resident was alert to person and place with no apparent injuries, and after the other was alert to person only and complained of hip pain. The DON confirmed there was no documentation of neurological assessments after either event, despite the facility's Falls-Clinical Protocol requiring documentation of neurological status after falls.
Failure to Coordinate Hospice Plan of Care: A resident with bipolar disease, schizophrenia, dementia, abnormal weight loss, and anxiety was referred to hospice after a change in condition and a DNRCC decision. Hospice nurse and aide visits occurred, but the record lacked documentation of the hospice services to be provided or visit frequency, and the DON confirmed the facility did not hold a care conference with the hospice provider, staff, and the resident’s representative to develop the plan of care. Facility staff were also unaware of the hospice schedule when they provided a shower.
A nurse failed to prevent contamination during a medication pass by touching multiple medication bottles and removing tablets and capsules into her ungloved hand before placing them in medication cups for two residents. The nurse handled ordered meds for one resident with psychiatric diagnoses and another resident with fractures, DM2, and COPD, and later confirmed she touched medications with her bare hand; the DON verified staff should not touch resident medications with bare hands.
A resident with chronic pain and moderate cognitive impairment was admitted without her pain medication, prompting her husband to bring in her prescribed narcotic. The medication was not administered, and there was a dispute between the LPN and the husband about whether the medication was returned. The facility did not report or investigate the alleged misappropriation, nor did it notify authorities or document the incident, despite conflicting accounts and staff awareness.
A resident with chronic pain and moderate cognitive impairment did not receive her prescribed pain medication upon admission, leading her husband to bring in medication from home. An LPN claimed to have returned the medication to the husband, but the husband reported he never received it. Despite conflicting accounts, facility leadership did not document the incident or initiate an investigation as required by policy.
Food Handling and Hand Hygiene Lapses During Meal Service
Penalty
Summary
Food was not handled in a manner to prevent contamination during meal service. During observation on 05/06/26 at 11:40 A.M., the Dietary Manager wore gloves to scoop pasta shells and green beans, then used the same gloves to touch serving utensils and plates before picking up a slice of garlic toast and placing it on lunch plates. During interview at 11:59 A.M., the Dietary Manager confirmed she should have used kitchen tongs to pick up the bread slices instead of the gloved hand that had already touched serving utensils and plates. Hand hygiene was also not performed between serving residents. Resident #3 had diagnoses including acute respiratory failure, generalized muscle weakness, contracture, dysphasia, major depressive disorder, anxiety disorder, and essential hypertension, and the MDS showed severe cognitive impairment and dependence for ADLs. Resident #36 had diagnoses including Parkinson's disease, schizophrenia, chronic bronchitis, COPD, bipolar disorder, muscle weakness, anxiety, and fibromyalgia, and the MDS showed cognitive intactness with moderate assistance needed for some ADLs and touch assistance for transfers. During observation on 05/04/26 at 11:38 A.M., a CNA passed out meal trays and did not wash or sanitize her hands between serving Resident #3 and Resident #36. The CNA confirmed she did not perform hand hygiene between residents and stated she should have sanitized her hands after passing out one plate and before touching another plate.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were conducted for residents included in the comprehensive care planning process. Based on medical record review, staff interview, resident representative interview, resident interview, and policy review, four of twelve residents reviewed for care planning were affected. The facility policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, stated the interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. Resident #7 was admitted with diagnoses including unspecified dementia, repeated falls, cognitive communication deficit, generalized weakness, type II diabetes, and chronic kidney disease. The record showed a care conference on 04/30/25, with the next documented care conference not occurring until 03/18/26. The DON confirmed the medical record did not support quarterly care conferences for this resident. Resident #3 had diagnoses including diabetes mellitus, obstructive and reflux uropathy, dementia, and a history of traumatic brain injury. The quarterly MDS dated 04/22/26 showed severe cognitive impairment and dependence for toilet hygiene and bathing, with partial/moderate assistance needed for bed mobility and transfers. Care conference notes were found only on 03/18/25 and 03/10/26, and the resident's representative stated he had only attended one care conference in the past year. The DON confirmed there was no documentation showing quarterly care conferences after 03/18/25. Resident #9 was admitted with diagnoses including chronic kidney disease, COPD, type two diabetes mellitus, epilepsy, and bipolar disorder. The record showed intact cognition and a DNR-CCA plan of care, with quarterly assessments completed on 03/12/25, 09/05/25, 03/06/26, and 04/23/26, and a comprehensive assessment completed on 12/10/24. Care conferences were documented on 03/04/25, 06/03/25, and 04/15/26, and the resident stated he was not sure what a care conference was. Resident #22 was admitted with diagnoses including type one diabetes mellitus, atherosclerotic heart disease, legal blindness, and peripheral vascular disease. The comprehensive MDS dated 04/03/26 showed moderate cognitive impairment and need for set-up assistance with eating, toileting, and bed mobility, and supervision for transfers. Only one care conference dated 04/15/26 was documented, attended by a nurse, a physical therapist, and the Administrator, with a note that the family member could not attend. The DON verified there was no other care conference documentation for Resident #22 or Resident #9.
Inaccurate Accounting of Resident Personal Funds
Penalty
Summary
The facility failed to maintain an accurate accounting of resident personal funds deposited with the nursing home for three residents reviewed. For one resident with COPD and intact cognition, petty cash receipts showed purchases from the resident needs fund, but the resident and staff initials/signatures on the receipts were similar in handwriting, and the trust ledger did not match the timing of the expenditures. For another resident with dementia with agitation and schizoaffective disorder, multiple petty cash receipts documented shopping purchases, but some receipts lacked resident initials, one had no initials, and the ledger contained deductions and withdrawals that did not align with the receipts, including one transaction posted to the wrong resident account. For a third resident with heart disease and neurocognitive disorder with behaviors, receipts also documented shopping purchases, but one receipt had the resident’s initials written in the same handwriting as staff and another had only staff initials, while the ledger reflected matching deductions. During interview, the Administrator verified the receipts were not completed accurately and lacked the required resident and witness signatures. The Administrator also verified that one receipt for the resident with dementia was posted to the wrong trust ledger and that receipts for two residents were not balanced with the ledger on the day the expenditures occurred. The facility did not provide its policy related to resident trust funds during the survey.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a resident’s significant weight loss. Resident #20 was admitted with diagnoses including diabetes mellitus, schizoaffective disorder, dementia with behavioral disturbances, and heart failure. The resident’s quarterly MDS indicated the resident was cognitively intact, required partial/moderate assistance with bed mobility and transfers, was dependent on staff for toilet hygiene, and needed set-up assistance with eating. The MDS also noted significant weight loss and that the resident was not on a physician-prescribed weight loss program. The medical record showed weekly weight orders and a no added salt, carbohydrate-controlled diet, but no orders for meal supplements. A significant weight loss note documented 5% weight loss over one month, 7.5% over three months, and 10% over six months, and stated the resident’s weight fluctuations were likely related to fluid shifts. The note did not document that the physician was notified of the significant weight loss. The RD stated staff are to notify the physician of any significant weight loss, and the DON confirmed the physician had not been notified and said she was not aware the resident had significant weight loss.
Failure to Complete Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary and a recapitulation of stay for two residents who were discharged from the facility. Resident #41 had diagnoses including Alzheimer's disease, COPD, delusional disorders, hypertension, and unspecified psychosis, and was transferred to another nursing facility after a care conference with the resident's guardian in which transfer status, medications, the most recent doctor note, weights, and code status were reviewed. The medical record for this resident contained no documentation showing that a discharge summary or recapitulation of stay was completed. Resident #44 had diagnoses including acute kidney failure, Parkinson's disease, asthma, dementia, and CHF, and the record showed an appeal was denied, the son was notified of the last covered day of service, and a planned discharge was set. The resident later transferred home, but the medical record contained no documentation showing that a discharge summary or recapitulation of stay was completed. The DON confirmed that both residents discharged from the facility and neither record had documentation supporting completion of these documents. The facility policy stated that when discharge was anticipated, a discharge summary was created and furnished to the provider assuming responsibility for the resident's care after discharge.
Incomplete Person-Centered Care Plans for Medication Monitoring and Hospice Services
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans with measurable objectives and timetables to meet resident needs for two residents reviewed. For Resident #31, the medical record showed an admission date of 08/23/24 with diagnoses of chronic obstructive pulmonary disease, hypertension, and major depression. The quarterly MDS dated 03/05/26 showed severe cognitive impairment, independence with bed mobility and transfers, supervision needed for toilet hygiene, and partial/moderate staff assistance needed for bathing. A physician order dated 03/27/26 prescribed Zoloft 50 mg by mouth every evening for depression, but the care plans contained no documentation of a comprehensive person-centered care plan to monitor the resident’s use of the antidepressant medication. For Resident #35, the medical record showed an admission date of 03/06/26 with diagnoses of bipolar disease, schizophrenia, dementia, abnormal weight loss, and anxiety. The significant change MDS dated 04/29/26 showed severe cognitive impairment, supervision needed with transfers, bed mobility, and eating, dependence on staff for toilet hygiene, and receipt of hospice services. The care plans contained no documentation of a comprehensive person-centered care plan for hospice services, including the hospice provider name, contact information, or types of services provided by hospice. During interview on 05/06/26 at 2:58 P.M., the DON confirmed the facility had not developed comprehensive person-centered care plans to address Resident #31's antidepressant use or Resident #35's hospice care and services.
Failure to Arrange Audiology Referral for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that a referral to an audiologist was arranged for a resident with impaired hearing as recommended. Resident #9 was admitted with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, epilepsy, and bipolar disorder, and the quarterly MDS assessment coded the resident with highly impaired hearing without hearing devices. The care plan identified a sensory impairment affecting participation in activities related to impaired hearing and vision, and interventions focused on activity participation and reducing background noise. An audiology visit documented that the resident had hearing loss, fetal alcohol syndrome that greatly affected hearing and vision, and left ear pain. The resident was treated for left-sided otitis media and ear wax impaction was removed, and the note included a referral to an audiologist for additional testing. A later NP progress note documented that the resident was hard of hearing, with the right ear being the best ear for communication. During observation and interview, the resident motioned for staff to speak into the right ear, stated he could not hear from the left ear and had very limited hearing in the right ear, and confirmed he did not have hearing aids and had not been evaluated for them. The Administrator verified that the referral to an audiologist was never made.
Failure to Document Neurological Evaluations After Unwitnessed Falls
Penalty
Summary
The facility failed to complete and document neurological evaluations after unwitnessed falls for one resident. The resident had an admission date of 10/08/13 and diagnoses including peripheral vascular disease, Alzheimer's disease, and aortic aneurysm. The resident's MDS assessment dated 02/24/26 showed severely impaired cognition, substantial to maximum assistance needed for transfers and bed mobility, no ambulation noted, and dependence on staff for toilet hygiene. The assessment also indicated the resident sustained a fall with major injury. Fall investigation documentation showed the resident had an unwitnessed fall on 01/17/26 and was found on the floor on the side of the bed; the resident could not recall what happened, was alert and oriented to person and place, and had no apparent injuries. A second unwitnessed fall occurred on 02/19/26, when the resident was found on the floor in front of the bed, was alert to person only, could not recall what happened, and complained of hip pain. The family and PA were notified after both events, but review of the fall investigations and medical record found no documentation that neurological evaluations were completed after either unwitnessed fall. The DON stated staff are to complete and document neurological evaluations after unwitnessed falls, and the facility policy titled Falls-Clinical Protocol required nurses to assess and document neurological status along with other findings.
Failure to Coordinate Hospice Plan of Care
Penalty
Summary
The facility failed to ensure collaboration with a hospice provider for development and implementation of a resident’s plan of care. The resident had an admission date of 03/06/26 and diagnoses including bipolar disease, schizophrenia, dementia, abnormal weight loss, and anxiety. A significant change MDS dated 04/29/26 showed severe cognitive impairment, supervision needed for transfers, bed mobility, and eating, and dependence on staff for toilet hygiene, and it also indicated the resident received hospice services. A physician order dated 04/24/26 referred the resident to hospice, and a nursing note dated 04/23/26 documented a care conference with the guardian in which the code status was changed to DNR Comfort Care and hospice was agreed to due to weight loss and change in condition. Hospice documentation showed nurse visits on 04/23/26, 04/24/26, 04/27/26, and 04/28/26, and hospice aide visits on 04/29/26 and 05/05/26. The hospice aide note on 05/05/26 stated facility staff provided a shower because they were unaware of the hospice schedule. The record contained no documentation describing the hospice services to be provided or the frequency of nurse or aide visits, and no documentation showing the facility and hospice provider collaborated to develop a plan of care. The DON stated the facility did not conduct a care conference with the hospice provider, facility staff, and the resident’s representative to develop the plan of care, and confirmed the record did not identify which hospice services were to be provided or how often.
Medication Administration Contamination During Pass
Penalty
Summary
The facility failed to ensure medications were administered in a manner to prevent contamination. During observation of medication administration, a registered nurse completed hand hygiene, then handled keys, unlocked the medication cart, and touched multiple medication bottles while locating ordered medications for two residents. The nurse removed medications from multi-dose bottles by pouring tablets and capsules into her ungloved hand before placing them into medication cups, and also handled individual medication cards and pushed a clonazepam tablet through a bubble pack into her ungloved hand before administering it to one resident. Resident #18 had diagnoses including severe bipolar disorder, schizoaffective disorder, and major depressive disorder. The resident’s quarterly MDS assessment indicated intact cognition and that the resident required set up assistance for eating and was independent with toileting, transfers, and bed mobility. Active physician orders included cholecalciferol 1000 units daily, docusate sodium 100 mg daily, clonazepam 1 mg three times daily, and ibuprofen 200 mg as needed. During the observed medication pass, the nurse touched multiple medication containers after hand hygiene and handled the resident’s cholecalciferol, docusate sodium, ibuprofen, and clonazepam without gloves. Resident #32 had diagnoses including wedge compression fractures, right-sided rib fractures, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The resident’s quarterly MDS assessment indicated intact cognition and that the resident required set up assistance with eating and supervision with toileting, bed mobility, and transfers. Active physician orders included calcium-vitamin D with minerals 600-400 mg, Colace 100 mg, sodium chloride 1 gram, and magnesium 400 mg twice daily. During the observed medication pass, the nurse again touched multiple medication bottles after hand hygiene and removed calcium-vitamin D, Colace, and sodium chloride by placing them into her ungloved hand before putting them into medication cups. The nurse later confirmed she touched medications with her bare hand and stated she should not have; the DON also verified nursing staff should not touch resident medication with their bare hands.
Failure to Report Alleged Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property involving a resident who was admitted with multiple medical conditions, including chronic pain, major depressive disorder, and moderate cognitive impairment. Upon admission, the resident's pain medication had not arrived from the pharmacy, so her husband brought in her prescribed Hydrocodone-Acetaminophen from home. The medication was not administered, and there was a dispute between the LPN and the resident's husband regarding whether the medication was returned. The LPN claimed to have returned the medication and provided a signed receipt, but the husband denied receiving the medication and stated he did not sign the receipt. The administrator and DON confirmed that the signature on the receipt did not match the husband's signature. Despite the conflicting accounts and the involvement of a controlled substance, the facility did not initiate a self-reported incident or conduct an investigation into the alleged misappropriation. Interviews with CNAs indicated they were aware of the situation and had observed questionable handling of narcotic medications by the LPN. The facility did not document the incident in the accident and incident log, did not notify authorities, and did not follow its own policy requiring prompt reporting and investigation of abuse, neglect, or misappropriation. No action was taken to suspend the employee or report the incident to the appropriate agencies.
Failure to Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to investigate an allegation of misappropriation involving a resident who was admitted with multiple medical conditions, including chronic pain, malnutrition, major depressive disorder, and moderate cognitive impairment. Upon admission, the resident's prescribed pain medication had not arrived, prompting her husband to bring in her Hydrocodone-Acetaminophen from home. The administrator instructed the nurse not to administer home medication, and the LPN claimed to have returned the medication to the husband. However, the husband reported that he never received the medication back. Despite conflicting accounts between the LPN and the resident's husband regarding the return of the medication, the facility did not initiate a Self-Reported Incident (SRI) or conduct an investigation into the missing medication. There was no documentation of the incident in the facility's Accident and Incident Log, nor was there an SRI filed for misappropriation. The facility's policy required prompt reporting and thorough investigation of all allegations of abuse, neglect, or misappropriation, but this protocol was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Union City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Randolph Nursing Home | 9.7 mi | — | 0 | 0 |
| Pineknoll Rehabilitation Centre | 9.7 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Greenville | 10.8 mi | ★★★★★ | 12 | 0 |
| Village Green Rehabilitation And Healthcare Center | 11.1 mi | ★★★★★ | 3 | 0 |
| Rest Haven Nursing Home Inc | 11.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Union City Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.