Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hartville Care Center during CMS and state inspections, most recent first.
A resident with paraplegia, weakness, obesity, and prior tibia injury was identified as needing 2-person assist with a sit-to-stand lift, but a CNA transferred the resident from the toilet without the lift and without the required second staff member after relying on the resident’s statement that a stand-pivot transfer was okay. The resident’s knees gave out, causing a fall onto both knees and resulting in bilateral tibia plateau fractures. Interviews showed staff were using shift reports, team sheets, and verbal updates, while therapy had not signed off on stand-pivot transfers for nursing staff.
Failure to Follow Transfer Assistance Plan Resulted in Fall and Bilateral Tibia Fractures
Penalty
Summary
The facility failed to keep a resident free from accidents when staff did not follow the resident’s transfer care plan and therapy direction. The resident had multiple significant diagnoses, including frontal lobe and executive function deficit following cerebral infarction, paraplegia, muscle weakness, morbid obesity, chronic pain, depression, and a prior left tibia fracture. The care plan identified the resident as a fall risk and stated the resident required two staff to assist with transfers using a sit-to-stand lift, while therapy notes documented ongoing transfer training and staff education. The resident’s therapy records showed that staff were being trained on transfers and that the resident still required assistance and verbal cues for safe movement. OT documentation noted staff training for wheelchair transfers at grab bars with minimum assistance of two staff for safety. However, on the day of the incident, a CNA assisted the resident from the toilet to the wheelchair without using the sit-to-stand lift and without the required second staff member. The CNA stated the resident said a single-person stand-pivot transfer was fine, and the resident’s knees gave out during the transfer. The resident fell onto both knees and later reported pain to both knees, with the left leg worse. X-rays showed bilateral tibia plateau fractures, and the resident was sent to the hospital for further treatment. Interviews with multiple staff members showed inconsistent understanding of the resident’s transfer status, with some staff relying on shift reports, team sheets, or resident statements rather than the care plan and therapy guidance. Therapy staff stated they had not signed off on stand-pivot transfers for nursing staff, and several staff acknowledged the resident should have been transferred with the sit-to-stand lift and two-person assistance.
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What surveyors actually found near you
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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 Hartville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Ridge Manor | 9.7 mi | ★★★★★ | 3 | 0 |
| Glenwood Rehabilitation & Health Care Center | 16.1 mi | ★★★★★ | 9 | 0 |
| Autumn Oaks Caring Center | 16.4 mi | ★★★★★ | 1 | 0 |
| Marshfield Care Center For Rehab And Healthcare | 22.3 mi | ★★★★★ | 7 | 0 |
| Heart Of The Ozarks Healthcare Center | 23.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.