Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ashtabula County Nursing Home during CMS and state inspections, most recent first.
A dependent resident with cognitive and mobility impairments, who required substantial to maximum assistance with rolling and was not identified as a fall risk, was transferred by mechanical lift to a shower gurney by an LPN and an agency CNA. The CNA then took the resident alone to the shower room, locked the gurney wheels, and rolled the resident away from herself toward a stationary side rail to remove an incontinence brief and lift sling, contrary to the manufacturer’s instructions that users should not be rolled away from the caregiver unless a second caregiver is on the opposite side. During this one-person gurney shower setup, the resident fell from the gurney to the floor, sustaining multiple injuries and later being found to have bilateral subdural hematomas and septic shock. Facility staff interviews, reenactments, and review of the gurney’s condition did not support the CNA’s claim that a wheel detachment caused the fall, and the facility’s investigation concluded the fall most likely resulted from human error and inadequate, individualized fall-prevention and supervision during gurney shower care.
A resident with multiple medical conditions was discharged from an LTC facility without the legal guardian's consent. The facility staff did not have the guardianship paperwork in the medical record, leading to the oversight. The resident's mother initiated the discharge, and the guardian was informed only after the discharge occurred. The facility's policy requiring a 30-day notice for discharge was not followed.
Failure to Provide Safe, Supervised Shower Gurney Care Resulting in Fall With Injury
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement comprehensive, individualized, and adequate fall-prevention interventions during shower care for a dependent resident using a shower gurney. The resident had moderate cognitive impairment, bilateral upper and lower extremity impairment, and was dependent on staff for toileting, hygiene, showers, transfers, dressing, and required substantial to maximum assistance with rolling left and right. Despite these needs, a quarterly fall risk assessment had determined the resident was not at risk for falls, noting forgetfulness, dependence on toileting checks and changes, and no prior fall history. On the day of the incident, the resident was transferred via mechanical lift by an LPN and an agency CNA from bed or chair to a shower gurney with both side rails up, and then transported without difficulty to the shower room. Once in the shower room, the agency CNA was the only staff member present. She locked the gurney wheels and began preparing the resident for a shower by removing the incontinence brief and mechanical lift sling. She reported that she rolled the resident away from herself toward the stationary side rail in order to remove these items, while the resident remained in the center of the gurney. This action was taken despite the manufacturer’s written instructions for the shower gurney, which state that exaggerated user movement or rolling to the edge may cause the gurney to tip and specifically instruct caregivers not to roll a user away from themselves unless a partner caregiver is on the opposite side. The facility’s shower/tub bath policy did not address this manufacturer precaution and did not instruct staff to avoid rolling residents away from themselves on a gurney unless another caregiver was present on the opposite side. During this one-person gurney shower setup, the resident fell from the gurney onto the floor. The CNA initially reported that a wheel came off the gurney, causing the fall, and staff arriving immediately afterward observed the resident on his right side on the floor next to the gurney, with the gurney slanted due to a wheel being off and the side rails in the up position. The resident had multiple abrasions, skin tears, bruising, and complained of pain. Subsequent hospital evaluation documented subdural collections/hemorrhage and septic shock. During interviews, the resident told his granddaughter and later surveyors that the aide had rolled him off the gurney, and facility staff, including the DON, LPN, and maintenance personnel, reported that reenactments and physical inspection of the gurney did not support the wheel-detachment explanation under normal use with body weight on the gurney. The facility’s internal investigation concluded that the fall most likely resulted from human error when the CNA rolled the resident too far while alone on the side opposite the stationary rail, contrary to the manufacturer’s instructions and without individualized, adequate supervision and fall-prevention measures during gurney shower care. The incident and investigation also revealed that the facility’s existing policies and assessments did not adequately address the resident’s fall risk and the specific hazards associated with shower gurney use. The fall risk assessment had not identified the resident as at risk for falls despite his dependence for mobility and rolling, and the shower/tub bath policy lacked guidance on safe rolling techniques on a gurney and the need for a second staff member when rolling a resident away from the caregiver. Manufacturer instructions for the gurney, including the prohibition against rolling a user away from the caregiver without a partner on the opposite side, were not incorporated into facility procedures or staff practice at the time of the incident. As a result, the resident was left under the care of a single CNA who rolled him away from herself on the gurney, leading to the fall with injury.
Failure to Notify Guardian of Resident Discharge
Penalty
Summary
The facility failed to ensure that the legal guardian of a resident was informed and gave consent for the resident's discharge. The resident, who had multiple medical diagnoses including pulmonary edema, Asperger's syndrome, diabetes, and dependence on renal dialysis, was discharged from the facility without the guardian's approval. The resident had moderate impairment in decision-making and required assistance with daily activities. The discharge was unplanned and initiated by the resident's mother, who was not the legal guardian. The facility's staff, including an LPN and the Social Service Director, did not have the legal guardianship paperwork in the resident's medical record, which led to the oversight. The LPN notified the physician of the resident's request to leave but did not contact the guardian due to the absence of guardianship documentation in the chart. The guardian was only informed of the discharge after it had occurred, during an unannounced visit to the facility. The facility's policy required a 30-day notice for discharge unless it was necessary for the resident's welfare, which was not adhered to in this case. The guardian expressed disagreement with the discharge and stated that the facility did not prepare the resident for a safe discharge. The resident was later placed in another facility and passed away due to complications from COVID-19 related pneumonia.
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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 Kingsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Club Ret Center I I I | 4.7 mi | ★★★★★ | 9 | 0 |
| Carington Park | 5.3 mi | ★★★★★ | 0 | 0 |
| Lake Pointe Rehabilitation And Nursing Center | 7.2 mi | ★★★★★ | 23 | 0 |
| Saybrook Landing | 8.2 mi | ★★★★★ | 0 | 0 |
| Jefferson Healthcare Center | 9.9 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 July 2026) and official state health department websites.