Above average — CMS composite of the measures below.
The next survey window likely opens around June 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 Ashtabula County Nursing Home during CMS and state inspections, most recent first.
Failure to identify PTSD triggers in care plans. Four residents with PTSD had care plans that did not document trauma history, known or potential triggers, calming strategies, or individualized trauma-informed interventions. Records showed behavioral symptoms and cognitive impairment in several residents, and staff interviews confirmed they did not know the residents’ triggers. The ADON also confirmed quarterly PTSD assessments were not completed for three of the residents.
Failure to treat a resident with respect and dignity during morning care. A resident with atrial fibrillation, hearing loss, acute and chronic respiratory failure with hypoxia, and moderately impaired cognition needed assistance with bathing, dressing, and transfers. During dressing assistance, a CNA reportedly responded in a rude manner when the resident reached for help to sit up, and the resident later described the interaction as rude and upsetting.
A resident with COPD, chronic respiratory failure, severe cognitive impairment, and oxygen use had a nebulizer mask observed sitting directly on the bedside table next to the nebulizer machine. The mask was not stored in a plastic bag or other clean container and was not dated, and an LPN confirmed it was uncovered and without a date. Facility policy stated respiratory tubing and nebulizer equipment should be stored in a clean plastic bag or dedicated container when not in use.
Hand hygiene was not performed during wound care for a resident with quadriplegia and chronic osteomyelitis. An LPN removed soiled gloves and put on clean gloves to continue dressing care without washing hands, despite facility policy requiring hand hygiene before and after dressing changes and after glove removal.
Failure to document influenza vaccine education for two residents. One resident was cognitively intact and another had a severe cognitive deficit; both received the flu vaccine, but the record showed no education was provided to the resident or responsible party before administration. The facility infection preventionist verified the missing documentation, and the facility policy required residents or legal representatives to receive information and education on vaccine benefits and potential side effects before vaccination.
Incomplete daily nurse staffing posting. The facility’s posted staffing report listed only the number of nurses, number of nurse aides, date, and census, but did not include the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. Review of multiple postings showed the same omission, and the ADON stated she was responsible for the posting and was unaware of the requirement.
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 identify PTSD triggers in care plans
Penalty
Summary
The facility failed to ensure trauma-informed care triggers were identified and addressed for residents with post-traumatic stress disorder (PTSD). Review of the records for four residents showed each had a diagnosis of PTSD, but their care plans did not document known or potential triggers, calming strategies, individualized interventions, or other trauma-related approaches. The facility policy required assessment for trauma history or signs of PTSD on admission, quarterly review, and identification of triggers, calming strategies, personal boundaries, communication preferences, and privacy needs. Resident #11 was admitted with PTSD, vascular dementia, psychotic disturbance, and anxiety. The quarterly MDS showed moderate cognitive deficits and behavioral symptoms directed toward others. The care plan noted depression and a recent inpatient psychiatric stay for medication management related to psychiatric issues and behaviors, but it did not identify PTSD triggers or interventions. A CNA and an LPN stated they did not know the resident had PTSD or what triggered behaviors, while the unit manager stated the resident’s triggers were loud noises from military service and confirmed the care plan lacked triggers. Resident #3 had PTSD and major depressive disorder, with a care plan noting risk for decline in mood related to PTSD, anxiety, and depression, but no documentation addressing PTSD triggers or interventions. Resident #76 had diagnoses including Alzheimer’s disease, PTSD, OCD, bipolar disorder, major depressive disorder, anxiety, and psychosis; the care plan contained no documentation related to PTSD, trauma history, triggers, calming strategies, or individualized interventions. Resident #81 had PTSD, bipolar disorder, and unspecified psychosis; its care plan also lacked documentation of trauma history, triggers, calming strategies, individualized interventions, or trauma-informed approaches. Staff interviews confirmed they did not know the residents’ PTSD triggers, and the ADON confirmed quarterly PTSD assessments were not completed for residents #3, #76, and #81.
Failure to Treat a Resident with Respect and Dignity
Penalty
Summary
Staff failed to ensure a resident was treated with respect and dignity during morning care. Resident #57 was admitted with diagnoses including atrial fibrillation, hearing loss, and acute and chronic respiratory failure with hypoxia, and the annual MDS indicated moderately impaired cognition and need for assistance with bathing, dressing, transfers, and toileting. During dressing assistance, CNA #249 was helping the resident get dressed when the resident reached for her hand to help sit up and reported that the CNA responded, "Don't touch me," which the resident said upset him and felt rude. The incident was reported to the DON with the resident's granddaughter present, and the resident later told the DON that the CNA had been rude and not very nice during the interaction. CNA #249 gave a different account, stating the resident pulled her down when reaching for her arm and denying that she said, "Don't touch me." During a later interview, the resident recalled the CNA being rude and yelling something, but he could not remember the exact words and did not indicate he felt abused.
Nebulizer Mask Left Uncovered and Undated
Penalty
Summary
The facility failed to ensure a nebulizer mask was stored in a manner to prevent contamination for one resident with COPD and chronic respiratory failure with hypoxia. The resident’s record showed severe cognitive impairment, shortness of breath with exertion and when lying flat, and oxygen therapy use. Physician orders included oxygen at 3 liters per minute via nasal cannula continuously and ipratropium-albuterol nebulizer treatment every six hours as needed for shortness of breath or wheezing. During observation, the resident’s nebulizer mask was seen sitting directly on and touching the bedside table next to the nebulizer machine. The mask was not stored in a bag and was not dated to show when it was last changed. On a later observation, the mask was again uncovered and touching the bedside table. An LPN present during the observation verified that the mask was uncovered and without a date, and stated nebulizer masks are to be changed weekly on Tuesdays, dated, and stored in a plastic bag when not in use. The facility policy stated that oxygen and nebulizer tubing should be stored in a clean, dry, cool space and placed in a clean plastic bag or dedicated respiratory storage container when not in use.
Hand hygiene not performed during wound care
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when proper hand hygiene was not performed during wound care for one resident. Resident #8 was admitted on 04/09/19 and readmitted on 05/03/23 with diagnoses including quadriplegia and chronic osteomyelitis. The quarterly MDS assessment identified the resident as cognitively intact with skin impairment of pressure areas, and the care plan noted risk for impaired skin integrity related to impaired mobility, catheter tubing, and quadriplegia, with interventions including wound care per order and checking dressings to the coccyx and left ischial wounds. During observation of wound care, three dressings were noted to be dry, intact, and dated appropriately. The LPN washed hands with soap and water and donned gloves, removed the old dressings from the right upper thigh and left buttock area, then removed the soiled gloves and put on clean gloves to finish the wound care without washing hands after removing the soiled gloves. The LPN verified that hand hygiene was not performed after removing the soiled gloves and before continuing wound care. The facility policy stated hand hygiene was required before and after direct resident contact, before and after changing a dressing, and after removing gloves.
Failure to Document Influenza Vaccine Education
Penalty
Summary
The facility failed to ensure education was provided to residents on the influenza vaccine before administration. Review of the medical record for Resident #8 showed an initial admission date of 04/09/19 and a readmission date of 05/03/23, with diagnoses including quadriplegia, chronic osteomyelitis, morbid obesity, bipolar disorder, and major depressive disorder. The quarterly MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact and received the influenza vaccine. The vaccine administration record showed the influenza vaccine was given on 09/26/25, and there was no documentation that education was provided before the vaccine was administered. Review of the medical record for Resident #22 showed an admission date of 12/21/24 with diagnoses including cerebral infarction, aphasia, and hemiplegia and hemiparesis following a cerebral infarction. The quarterly MDS 3.0 assessment dated [DATE] indicated the resident had a severe cognitive deficit and received the influenza vaccine. The vaccine administration record showed the influenza vaccine was given on 10/01/25, and there was no documentation that education was provided before administration. During interview on 07/08/26 at 2:12 P.M., RN #202, identified as the facility infection preventionist, verified that Residents #8 and #22 had no record of education being provided to them or their responsible party prior to influenza vaccine administration.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility did not ensure that the daily posted nurse staffing report included all required information. During an initial tour, the posted document titled Report of Nursing Staff Directly Responsible for Resident Care showed only the number of nurses, number of nurse aides, the date, and census, but did not include the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. Review of the staffing postings from 06/08/26 through 06/30/26 showed the same omission on each report. An interview with the ADON revealed she was responsible for creating the daily nursing staffing posting and was unaware that the regulation required the total number and actual hours worked to be included; she confirmed the hours had not been posted as required.
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 | ★★★★★ | 5 | 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 October 2026) and official state health department websites.