Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Obion County Nursing Home during CMS and state inspections, most recent first.
Administration failed to maintain effective financial controls over payroll and the facility checking account after bringing payroll back in-house. The administrator, a social worker/bookkeeper, and an HR/bookkeeper all had authority to process payroll, alter pay rates, track PTO on an internal spreadsheet, and sign checks without board approval. Review of payroll records, timekeeping data, and CPA analyses showed that these three staff members received large, unauthorized cash-outs of vacation and holiday time and reported extensive overtime, far exceeding facility policy and not supported by actual work hours. Time entries for the two bookkeepers were largely manual rather than actual punches, and audit logs showed self-directed pay rate changes. Interviews with the governing board, current administration, and other staff confirmed that Medicare, Medicaid, private pay, and insurance revenues were deposited into the same account from which these inflated payroll disbursements were made, and that there were no effective checks and balances or independent verification of accrued PTO or overtime, affecting funds available for all residents’ care.
The governing body failed to provide effective oversight of the administrator, payroll system, and the facility’s primary bank account, into which Medicare, Medicaid, insurance, and private resident payments were deposited. Facility policy assigned the board responsibility for establishing management policies and ensuring the administrator reported on audits, budgets, staffing, and supplies, but the facility could not produce any governing body policy predating a recent version, and board members described limited visibility into operations. Payroll had been brought back in-house using a new bookkeeping system, and over a 19‑month period the administrator and two bookkeeping staff cashed out more than $140,000 above allowable benefits, while the board received only summarized financial data and did not review detailed payroll records or prior accruals as recommended by a CPA. Personnel manuals from later years were never presented for approval, policy changes were made without board authorization, and key office positions remained vacant, all while the board relied on verbal assurances from the administrator and annual audits as their primary checks and balances. This lack of oversight and accountability for financial operations had the potential to affect all residents receiving care.
A resident with severe cognitive impairment and total dependence for ADLs was manually transferred by two CNAs without the required mechanical lift, contrary to the care plan and facility policy. After the transfer, the resident sustained a right humerus fracture, which was not promptly reported or documented by the LPN who assessed the injury. The delay in reporting and failure to follow safe transfer protocols resulted in actual harm to the resident.
The facility failed to follow infection control practices during medication administration and wound care. An LPN used a single eyelid wipe for both eyes and did not change gloves between treatments. Another LPN administered a contaminated medication and did not change gloves between treating clean and soiled pressure ulcers. The DON confirmed these actions were against facility policies.
A resident with severe cognitive deficits was found in a wheelchair with a seat belt they could not remove, contrary to the facility's 'Restraint Free Environment' policy. Despite being identified as high risk for falls, the resident was unable to release the seat belt, which functioned as a restraint. The ADON confirmed the resident's inability to remove the belt, highlighting a failure to ensure the resident's freedom from physical restraints.
A resident with a complex medical history fell from a lift device in an LTC facility, resulting in a fracture of the left humerus. The incident occurred when the lift pad straps broke during a transfer, causing the resident to fall to the floor. Staff interviews revealed that the lift pads were supposed to be checked for fraying before use, but the facility did not contact the manufacturer about the broken sling or investigate the cause of the failure.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The nursing staff did not obtain a physician's order for the catheter, and the care plan did not include all necessary catheter care. The resident, who was cognitively intact and had multiple diagnoses, was observed with urine draining into a catheter bedside bag. The DON confirmed the need for an order and care plan for the catheter.
A facility failed to provide adequate dialysis care and communication for a resident with multiple diagnoses, including Stage 5 Kidney Disease. The facility did not document monitoring of the resident's vascular access site on several occasions and lacked communication with the dialysis clinic. The resident was severely cognitively impaired and required dialysis three times a week, but the facility did not consistently document the necessary monitoring and communication, leading to a deficiency.
The facility failed to accurately post nurse staffing information, with missing RN hours on multiple days. An observation confirmed the absence of RN hours on the staffing posting, and the Administrator acknowledged the requirement for accurate postings.
Two LPNs at the facility failed to adhere to medication administration protocols, resulting in an 8% error rate. One LPN did not wait the recommended time between administering two eye medications to a resident with glaucoma, while another LPN failed to give a prescribed vitamin to a resident with multiple health conditions. The DON confirmed these errors.
Failure of Administrative Oversight Allowed Payroll Mismanagement and Excessive PTO Cash-Outs
Penalty
Summary
Administration failed to ensure appropriate checks and balances over the facility’s payroll system and checking account after payroll was brought back in-house. The governing body had appointed an appropriately licensed administrator who, per job description, was responsible for overall facility operations, instituting controls to ensure efficient and economical operation, limiting overtime, certifying payrolls, and ensuring timely deposits. However, the personnel plan and benefit structure implemented by the administrator was not approved by the governing body, and the facility relied on a manually maintained spreadsheet for tracking staff vacation, sick, holiday, and compensatory time. Staff could not independently verify their accrued time and had to rely on the social worker/bookkeeper to report balances. When payroll was moved from an outsourced vendor back into the facility, three office staff members—the administrator, the social worker/bookkeeper, and the HR/bookkeeper—had access to payroll records, the bookkeeping system, and the facility’s checking account, and all three could sign checks without board approval. Review of W-2s and payroll stubs showed that, after payroll was brought in-house, these three employees received large increases in total compensation, including substantial cash-outs of vacation and holiday time and significant overtime payments. Timeclock records showed that for the two bookkeepers, most time entries were manually entered rather than recorded by actual punches, and both reported very high overtime hours despite interview statements from another RN/administrative assistant that these two did not work overtime. The benefit plan limited vacation cash-out to no more than three days per pay period, but payroll records and CPA analysis showed that the three employees cashed out holiday and vacation time far in excess of policy limits. External CPA review of payroll and bank activity over a 19‑month period identified that the social worker/bookkeeper, HR/bookkeeper, and administrator collectively received $142,627.44 more in holiday and vacation cash-outs than allowed by facility policy, even under generous assumptions about maximum accruals. The bookkeeping system audit trail showed that the social worker/bookkeeper changed her own hourly rate and the administrator’s hourly rate upward during the audit period, then changed them back. Interviews with the board chairman, the current administrator, the RN administrative assistant, and the business office manager confirmed that the three office staff controlled which bills were paid, wrote and signed checks, and processed payroll without effective oversight or dual controls. The chairman reported that the three employees “took the money from the bank account,” which was funded by Medicare, Medicaid, private pay, and insurance revenues, and acknowledged that the facility was probably not administered as it should have been. The surveyor concluded that administration failed to provide oversight of payroll and staff with access to the checking account, resulting in financial mismanagement that had the potential to affect all residents whose care depended on those funds. The facility’s own policies required the administrator to implement procedures and controls to meet budgetary projections, limit overtime, and ensure efficient operation, and the board of directors was to oversee administration with proposals directed to them for consideration. Nonetheless, the administrator relied on the payroll clerk’s spreadsheet for tracking compensated absences, did not verify her own pay or the pay of the two bookkeepers, and did not monitor overtime or cash-outs against policy limits. The auditors found no reliable compensated absences report to support the large cash-outs, and the administrator acknowledged that she trusted staff under her, did not review her check stubs, and did not check the bookkeepers’ time even though she knew they were not working overtime. The lack of segregation of duties, absence of independent verification of accrued time, and failure to require board approval or dual signatures for payroll-related disbursements allowed the three employees to manipulate payroll and cash-outs using funds derived from Medicare, Medicaid, private pay, and insurance payments for resident care.
Governing body failed to oversee administrator, payroll, and facility bank account
Penalty
Summary
The deficiency involves the governing body’s failure to provide effective oversight of facility management and financial operations, including payroll and the primary facility bank account into which Medicare, Medicaid, insurance, and private resident payments were deposited. Facility policy dated 10/9/2025 stated that the governing body was legally responsible for establishing and implementing policies for management and operation of the facility, appointing an administrator who was responsible for management, and ensuring a process for the administrator to report on audits, budgets, staffing, and supplies. The facility was unable to produce any governing body policy that was in effect prior to 10/9/2025. Board members and the chairman described their role as mainly policy-making and oversight, with the administrator as the only employee of the board, but they relied largely on verbal reports and limited written financial information from the administrator. Governing body minutes showed that payroll had been brought back in-house after previously being outsourced, and that a new bookkeeping system was implemented. Over multiple meetings, the board received high-level financial reports from a CPA, including reports of profits and losses, but there were gaps in financial reporting, such as a meeting where financials were not reported due to the absence of the administrator and CPA. The minutes also documented that personnel manuals from 2022 and 2023 were never presented to the board for approval, even though earlier manuals had been approved, and that key office positions such as Social Services, Human Resources, and Business Office Manager were vacant. Board members later learned that policy manuals had been revised without board approval and that multiple versions of the policy manual were in circulation. A spreadsheet from CPA Firm #1 covering a 19‑month period showed that the administrator and two bookkeeping staff cashed out a total of $142,627.44 over the maximum benefit allowed by facility policy. An analysis from the CPA identified three employees who far exceeded the window for payroll payouts after payroll was brought back in-house and recommended that the board review prior auditors’ accruals for vacation, holiday, and sick leave and interview prior administrators about vacation restrictions during COVID. The chairman later acknowledged that he did not think the board had reviewed those accruals or discussed the CPA’s letter. Interviews with board members revealed that their primary checks and balances were annual audits and review of summarized financial statements, that they did not have detailed visibility into payroll or individual salaries, and that they were unaware of staff turning in hours worked at home. The board members stated they were blindsided when an external auditor identified significant unexplained salary increases for the administrator and two bookkeeping staff, and they acknowledged that the governing body had “dropped the ball” on ensuring the administrator was held accountable and that policy changes and financial operations were properly reviewed. The failure of the governing body to oversee the administrator, payroll system, and bank account was determined to have the potential to affect all 45 residents in the facility. The chairman reported that during the tenure of a prior administrator, payroll had been outsourced to an out-of-state firm without the board’s knowledge, which contributed to that administrator’s departure. Afterward, the administrator and a bookkeeper recommended bringing payroll back in-house, and the board accepted their assurances that there were no problems. The chairman stated that he questioned the administrator and visited the facility but relied on the information provided and did not receive the level of financial detail he felt was needed. Board members described that they received total salary figures as a blanket line item and general expense breakdowns, but not detailed salary registers or clear tracking of compensated absences. One board member stated that the governing body’s oversight and visibility into operations were limited and that they had not been given copies of the policy manual, despite the policy requiring a process for holding the administrator accountable for reporting on management and operations. Another board member linked the unapproved 2023 personnel handbook changes, including wording that allowed staff to cash in time, to the financial issues, noting that the way the policy was written contributed to increased payouts. Throughout interviews, board members and the chairman acknowledged that they relied heavily on trust in the administrator and did not implement or follow through on robust checks and balances to detect or prevent mismanagement of payroll and the facility’s bank account.
Failure to Follow Safe Transfer Policy and Timely Injury Reporting Results in Resident Harm
Penalty
Summary
Facility staff failed to follow established policy for safe resident handling and transfer, resulting in harm to a cognitively impaired resident who required two-person assistance and a mechanical lift for all transfers. On the day of the incident, two CNAs transferred the resident from bed to a shower chair and then to a wheelchair using manual lifting techniques, rather than the required mechanical lift, despite the resident's care plan specifying the use of the lift with two staff present. Video footage confirmed that the mechanical lift was not used during these transfers, and staff statements corroborated that manual lifting occurred. Approximately three hours after the transfer, one of the CNAs reported the resident's injury to an LPN, who was observed on video assessing the resident's arm but failed to report the incident to administration or document the assessment as required by facility policy. The injury, a comminuted fracture of the right humerus, was not formally identified until the following day when another CNA noticed swelling and bruising and reported it to a different nurse, who then initiated appropriate medical evaluation. The delay in reporting and assessment resulted in a delay in diagnosis and treatment of the resident's injury. Interviews and written statements revealed that the involved staff were aware of the injury and the improper transfer method but chose not to report the incident immediately, with one LPN instructing the CNAs not to disclose the event to avoid disciplinary action. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, suffered actual harm as a result of these failures to adhere to policy and promptly report and document the injury.
Infection Control Deficiencies in Medication and Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration and pressure ulcer care. Observations revealed that LPN C did not follow proper hand hygiene protocol by using her bare wet hand to turn off the faucet after washing her hands. LPN B administered a contaminated medication to a resident after it fell on the bedside table and the resident's chest. Additionally, LPN B did not change gloves or perform hand hygiene between treating clean and soiled pressure ulcers on a resident's knees. Further deficiencies were noted with LPN A, who used a single eyelid wipe for both of a resident's eyes, contrary to the instructions to use one wipe per eye. LPN A also failed to change gloves or perform hand hygiene between administering eye drops and applying cream to the resident's legs and feet. The Director of Nurses confirmed that these actions were not in compliance with the facility's infection control policies, which require the use of a dry paper towel to turn off faucets, discarding contaminated medications, and proper glove and hand hygiene during treatments.
Failure to Maintain Restraint-Free Environment for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy, titled 'Restraint Free Environment,' defines physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, observations revealed that a resident with severe cognitive deficits, as indicated by a BIMS score of 0, was consistently found in a wheelchair with a seat belt that they could not remove. The resident, who has diagnoses including Dementia and Anxiety, was unable to release the seat belt when encouraged to do so by staff. The resident's care plan identified them as high risk for falls due to confusion and unawareness of safety needs, recommending the use of a seatbelt alarm in the wheelchair. However, during an interview, the Assistant Director of Nurses acknowledged that the resident could not release the seat belt on demand, indicating that the device was indeed functioning as a restraint. This oversight demonstrates a failure to adhere to the facility's policy of maintaining a restraint-free environment, as the resident was unable to remove the seat belt independently.
Resident Injury Due to Lift Device Failure
Penalty
Summary
The facility failed to identify, evaluate, and analyze the cause of accident hazards, leading to a significant incident involving a resident. On 12/27/2024, a resident fell from a lift device during a transfer, resulting in a fracture of the left humerus. The incident occurred when the straps of the lift pad broke, causing the resident to fall approximately 4-5 feet to the floor. The resident sustained injuries including a left shoulder fracture and a subdural hematoma. At the time of the incident, the resident was being transferred by a Certified Occupational Therapy Assistant and two Certified Nursing Assistants. The resident involved had a complex medical history, including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Heart Failure, and Dementia. The resident was chairbound and had a history of intermittent confusion. Despite these conditions, the facility's Fall Risk Evaluation did not indicate any falls in the past three months, and the resident's fall risk score was 11.0. The incident note detailed that the resident was found lying face down on the floor with complaints of pain and altered mental status, and was subsequently transported to the hospital for evaluation and treatment. Interviews with staff revealed that the lift pad used during the transfer had broken straps, which were supposed to be checked for fraying before use. The facility's policy required the resident environment to be free of accident hazards and for staff to implement interventions to reduce risks. However, the facility did not contact the manufacturer about the broken sling, which was reportedly within its usage timeframe. The facility also failed to investigate the cause of the sling failure to prevent future incidents.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for an indwelling urinary catheter for a resident. The facility's policy required catheter care to be performed every shift and as needed, but the nursing staff did not obtain a physician's order for the catheter. The resident, who was admitted with diagnoses including pneumonia, diabetes, lymphedema, and a stage 2 pressure ulcer, was cognitively intact as indicated by a Brief Interview for Mental Status score of 15. The care plan for the resident did not include all necessary catheter care related to the indwelling Foley catheter. An observation revealed the resident sitting in a wheelchair with urine draining into a catheter bedside bag. The Director of Nursing confirmed that the resident should have had an order and a care plan for the indwelling catheter care.
Failure in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care and communication for a resident requiring such services. The facility's policy on hemodialysis mandates communication with the dialysis center and monitoring of the dialysis site for signs of infection. However, the facility did not document the monitoring of the resident's vascular access site on several occasions, specifically on 2/24/2025, 3/7/2025, 3/11/2025, and 3/14/2025. Additionally, there was a lack of documented communication with the dialysis clinic regarding the resident's care, as confirmed by interviews with the LPN and the Director of Nursing. The resident involved was admitted with multiple diagnoses, including Stage 5 Kidney Disease, Renal Dialysis, Bipolar Disorder, Diabetes Mellitus, Hypertension, and Atrial Fibrillation. The resident was severely cognitively impaired, as indicated by a BIMS score of 00. Despite having physician orders for dialysis three times a week, the facility did not consistently document the necessary monitoring and communication required for the resident's dialysis care, leading to a deficiency in the standard of care provided.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the accuracy of its posted nurse staffing information for 24 out of 33 days during the survey period. Specifically, the Daily Staffing Posting lacked Registered Nurse (RN) hours on multiple dates, including 2/13/2025, 2/14/2025, 2/17/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025, 2/26/2025, 2/27/2025, 2/28/2025, 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/8/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/14/2025, and 3/19/2025. An observation on 3/19/2025 at 9:00 AM confirmed that the staffing posting for that day was blank for RN total hours. During an interview on the same day, the Administrator acknowledged that the Daily Staff Posting should be completed accurately and that RN hours should not be left blank.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that medications were administered with a medication error rate of less than 5%, resulting in an observed error rate of 8%. This deficiency involved two nurses, LPN B and LPN C, who were responsible for administering medications. In one instance, LPN C administered two different eye medications to a resident with glaucoma without waiting the recommended five minutes between applications, as specified in the facility's policy and the manufacturer's instructions. This resulted in a medication error during the administration process. Additionally, LPN B failed to administer a prescribed multiple vitamin tablet to another resident during the morning medication round. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, dementia, and osteoarthritis, did not receive the vitamin as ordered by the physician. The Director of Nursing confirmed that the vitamin should have been administered according to the physician's orders, highlighting a lapse in adherence to medication administration protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Union City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Union City Health And Rehabilitation | 5 mi | ★★★★★ | 3 | 1 |
| The Waters Of Union City , Llc | 5.2 mi | ★★★★★ | 4 | 0 |
| Fulton Nursing And Rehabilitation, Llc | 14.9 mi | ★★★★★ | 0 | 0 |
| Vanayer Senior Living And Rehabilitation | 15.4 mi | ★★★★★ | 4 | 0 |
| Diversicare Of Martin | 15.6 mi | ★★★★★ | 0 | 0 |
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