Stellar Care Center: Memory Unit Left Understaffed - OH
That was the routine on the memory care unit at Stellar Care Center, according to multiple staff members and family members who spoke with inspectors during a complaint investigation completed September 30, 2025. One certified nursing assistant at a time. Sometimes one nurse covering both upstairs and downstairs. Residents with dementia, residents who sought exits, residents who needed constant supervision — and a single set of eyes trying to cover all of it.
"It makes you sick to come to work," one staff member told inspectors, "and knowing you will be by yourself and what if something happens."
That staff member described the math of it plainly. If the nurse assigned to the unit also had A-hall responsibilities, she was passing medications upstairs and downstairs, answering call lights, conducting assessments, trying to keep track of residents in two places at once. You cannot be two places at once. The staff member said day shift was worse — everyone was awake, meals were happening, the unit was in full motion — and still, that was all that was provided on every shift.
The inspection was triggered by complaints. Two of them, filed separately, that inspectors folded into a single investigation.
CNA #28 told inspectors the problem wasn't just about being stretched thin. It was about what happened in the gaps. When you're doing activities of daily living care, you don't know how long you'll be in that room. Could be a few minutes. Could be longer. During that entire stretch, there is no one monitoring the other residents. "This was a huge safety concern," the aide said. "So many things could happen at that time, and you were not able to see what was going on."
CNA #30 described the same bind from a different angle: activities on memory care were nearly impossible to run with one person because you still had to keep an eye on everyone. You have to stay with the residents. You cannot step away to set something up, retrieve materials, or manage a resident who's agitated without losing sight of everyone else.
An anonymous staff member, interviewed just before 1 a.m. on September 23, described the scenario that kept coming up in every interview: an emergency. "If there is an emergency, it's scary," the staff member said. The logic was simple and hard to argue with. If you have no eyes on the floor and something goes wrong, when will you see it? How will you notify someone? The nurse is upstairs trying to pass medications. The aide is in a room. The hallway is empty.
The staff member said it was impossible — not difficult, not challenging, impossible — for one aide to be alone on memory care and keep an eye on everyone while providing timely, quality care.
Resident #26 was placed on the memory care unit specifically because she was seeking exits. Her family told inspectors they were informed the unit would offer better supervision because it had fewer residents. What they found was something different. They expected crafts, cooking, movies, word searches, puzzles, coloring. They had seen, at another facility, residents doing volleyball, exercising, participating in activities that kept them engaged and moving. At Stellar Care Center's memory care unit, they said, that wasn't what they encountered.
The family said they did not feel comfortable with fewer than two staff members on the unit at any time, given the level of attention the residents required.
Resident #35's family told inspectors that activities happened sometimes, usually around holidays. That was the extent of it. They said they believed more than one staff member was needed on the unit, because otherwise the residents would be neglected. They used that word.
The Activity Director's job description, dated May 2022, laid out what the role was supposed to look like. The AD was responsible for supervising a program that met the physical, social, cultural, spiritual, emotional, and recreational needs of each resident. The AD was supposed to plan, develop, organize, implement, evaluate, and direct the activity program. Assess individual and group needs. Develop meaningful morning, afternoon, evening, and special programs. Prepare and post a monthly schedule. Coordinate, direct, and conduct all planned activities.
The gap between that job description and what families described finding on the unit is where the inspection report plants its flag.
The facility also had a dementia policy, updated as recently as April 2025, that called for staff and physicians to review the physical, functional, and psychosocial status of individuals with dementia and to summarize each person's condition, complications, and functional abilities. The policy existed. The inspection report cites it. What the inspection report documents, through staff and family interviews conducted across nearly two weeks in September 2025, is a unit where the people working it said they couldn't safely do their jobs and the people visiting it said their family members weren't getting what a memory care unit is supposed to provide.
The staffing concern and the activity concern are related. They are, in some ways, the same concern. A single aide trying to monitor a floor of dementia residents cannot simultaneously run activities. A nurse bouncing between two floors cannot provide the kind of oversight a memory care unit requires. When the staff member said the unit could go 15 minutes, sometimes longer, with something happening in a room that nobody would see — that's not a hypothetical. That's the structure of every shift.
Inspectors classified the harm level as minimal harm or potential for actual harm, affecting many residents.
The family of Resident #26 said they were told memory care would mean better supervision. They were told there were fewer residents, that their family member would get more attention. They said nobody explained what made memory care beneficial or what it was supposed to offer. They were making a decision about where to place someone they loved, someone who was trying to leave, and the information they received didn't match what they found.
What they found was one aide. A floor with no eyes on it. Activities that happened around holidays, if they happened at all. And staff who said, in interview after interview, that they knew it wasn't safe and came to work anyway because there was nobody else.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stellar Care Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 12, 2026 · Our methodology
STELLAR CARE CENTER in WOODSFIELD, OH was cited for violations during a health inspection on September 30, 2025.
One certified nursing assistant at a time.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.