Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canfield Acres Llc Dba Windsor House At Canfield during CMS and state inspections, most recent first.
The facility failed to report a resident-to-resident verbal abuse incident to the state agency as required by its abuse prevention policy. A resident with mild cognitive impairment and a history of aggressive behavior, treated with Divalproex Sodium, yelled expletives at another cognitively intact resident and threatened to hit that resident’s head against a table, believing the resident was his sister. Staff confirmed awareness of the resident’s history of mistaking this peer for his sister and that the verbal threat was directed toward that specific resident. However, the incident was not submitted as a self-reported incident because staff did not consider it verbal abuse, despite a facility policy defining verbal abuse as disparaging or derogatory language within hearing distance of residents regardless of their ability to comprehend.
A resident with severe cognitive impairment and dependence for transfers was left waiting in bed while repeatedly calling out for help after activating the call light. An RN turned off the call light, told the resident someone would be right in, and left without immediately notifying other staff; the resident was not transferred with a mechanical lift until about an hour after first requesting assistance.
A resident's funds authorization form was electronically signed by a family member, but the required witness signature was left blank. The BOM was unsure how witnessing worked with e-signatures, and the AD stated that if only one family member was present, only that signature was completed. The AD and RQA/RN confirmed the form was not witnessed as required by facility policy.
The facility failed to report allegations of physical abuse involving two residents to the state agency within the required two-hour timeframe. In one case, a resident reported being hit by another resident, but the incident was not reported until the next day. In another case, a former resident alleged rough treatment by an STNA, but the report was delayed several hours. The facility's policy requires immediate reporting, which was not followed.
A facility failed to update a resident's care plan to include hospice admission and new skin impairments, despite the resident's complex medical conditions. Interviews with nursing staff confirmed the absence of necessary care plans, violating the facility's policy on coordinated care.
A resident with a history of dementia and an indwelling urinary catheter was not properly monitored after showing signs of a UTI. Despite notifying the physician and receiving an antiemetic order, there was no documented monitoring of fluid intake, urinary output, or vital signs until several days later when increased confusion was reported. The facility's policy on change of condition was not followed.
A facility failed to coordinate care between hospice and facility staff, leading to a deficiency in pressure ulcer prevention for a resident. Despite being at risk, the resident developed new skin issues that were not communicated to the facility by the hospice nurse. The facility was unaware of these issues until informed by the resident's family. The care plans were not updated to reflect the resident's hospice care or skin conditions, and there was a lack of documentation and communication between hospice and facility staff.
The facility failed to ensure accurate and complete medical records for two residents. One resident's complaints of pain and leg rotation were not documented, and another resident's frequent refusals to get out of bed were not accurately recorded. Staff interviews confirmed an overall problem with documentation.
Failure to Report Resident-to-Resident Verbal Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report a resident-to-resident verbal abuse incident to the state agency as required by regulation and facility policy. One resident had a history of stroke, expressive language disorder, metabolic encephalopathy, anxiety disorder, and vascular dementia, and was documented as cognitively intact on a recent MDS. Another resident had metabolic encephalopathy, muscle weakness, and mild cognitive impairment, and was receiving Divalproex Sodium for aggressive behavior. A progress note documented that the resident with mild cognitive impairment yelled at the cognitively intact resident, used expletive language, and threatened to hit the resident’s head against a table, believing the resident was his sister. The behavior care plan for the resident with mild cognitive impairment, initiated on the same day as the incident, identified potential for verbal aggression toward staff and other residents related to dementia. Interventions included medication administration, analysis and documentation of triggers and de-escalation strategies, assessment of needs, environmental modification, and monitoring and documentation of behaviors and any signs of danger to self or others. Staff, including the Social Services Director and Regional QA Nurse, confirmed that the verbally aggressive resident believed the other resident was his sister and that staff were aware of this history and knew who he was speaking to during the incident. Despite this, the incident was not reported to the state agency as a self-reported incident (SRI). The Regional QA Nurse stated the facility did not view the situation as verbal abuse because the aggressive resident had impaired cognition and the other resident was reportedly unaware that the yelling was directed at her. Review of the facility’s abuse prevention policy showed that verbal abuse is defined as the use of disparaging or derogatory language within hearing distance of residents, regardless of their ability to comprehend or disability, and that all alleged and suspected abuse must be reported immediately to the department of health via online SRI submission. Review of the facility’s self-reported incidents confirmed there were no incidents reported around the date of the documented verbal threat, leading to the finding that the facility failed to report the suspected verbal abuse incident as required.
Failure to Respond Promptly to Call Light and Assist Resident with Dignity
Penalty
Summary
The facility did not ensure Resident #32 was treated with respect and dignity when the resident needed assistance. Resident #32 was admitted with diagnoses including contracture of an unspecified joint, muscle wasting and atrophy, lack of coordination, hypertension, difficulty walking, and muscle weakness. The physician ordered a mechanical lift for all transfers, and the care plans identified the resident as needing assistance with self-care and transfers, including reminders to use the call light and ask for help before self-transferring. Assessments showed the resident was dependent on staff for chair/bed-to-chair transfers and had severe cognitive impairment. On observation, Resident #32 was in bed with the call light on and was repeatedly calling out for help while RN #306 was standing at the nurse’s station next to the resident’s room. RN #306 acknowledged awareness of the call light and stated staff had already been in the room five times. The RN entered the room, asked if the resident wanted to get up, turned off the call light, told the resident someone would be right in, and left without alerting other staff. The resident continued waiting in bed, turned the call light back on, and kept calling out until CNAs #338 and #348 began transferring the resident out of bed with a mechanical lift one hour after the resident was first observed requesting assistance. The QA nurse stated the expectation was that the call light would stay on until care was provided or the resident’s need was immediately communicated to additional staff. The facility policy required call lights to be answered promptly and staff not to make residents feel too busy to provide assistance.
Unwitnessed Resident Funds Authorization
Penalty
Summary
The facility failed to ensure that authorizations for resident funds were witnessed as required for one resident reviewed for resident funds. Resident #37 was admitted with diagnoses including anemia, vitamin D deficiency, subclinical iodine-deficiency hypothyroidism, severe protein-calorie malnutrition, and malignant neoplasm of the rectum. The resident was her own responsible party and was documented as cognitively intact on the quarterly MDS assessment. Review of the resident funds disposition form showed that the form was electronically signed by the resident's brother, but the witness signature line was left blank. During interviews, the BOM stated she was not sure how witnessing worked with electronic signatures, and the AD explained that during admission paperwork she completed the form with the resident or family on her computer and, if only one family member was present, only that signature was completed. The AD and RQA/RN confirmed that Resident #37's resident funds authorization form was not witnessed and should have been. The facility policy stated that written authorization requires a witness signature and that the witness cannot be an employee of the facility or organization.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of physical abuse involving two residents to the state agency, as required by regulations. The first incident involved a resident who reported being hit on the hand with a phone by another resident. This incident occurred on a Saturday afternoon, but the facility did not create a self-reported incident (SRI) report until the following morning, resulting in a delay in notifying the state agency within the mandated two-hour timeframe. The facility's administrator confirmed the delay was due to not being informed of the incident until the next day. The second incident involved a former resident who alleged that a state-tested nursing assistant (STNA) was rough and intentionally hurtful while providing care. The resident left a voicemail after business hours, which was not addressed until the following morning. The facility created an SRI report several hours after being notified, again failing to meet the two-hour reporting requirement. The administrator could not provide a reason for the delay. The facility's policy mandates immediate reporting of alleged abuse to the Department of Health, which was not adhered to in these cases.
Failure to Update Hospice and Skin Care Plans
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and updated for a resident who was admitted to hospice care and had multiple skin impairments. The resident, who had a range of diagnoses including severe dementia, kidney disease, and colon cancer, was admitted to hospice care but did not have a corresponding hospice care plan in place. Additionally, the care plan was not updated to reflect new skin impairments, including deep tissue injury to the left heel, moisture-associated damage to the buttocks, and groin swelling. Interviews with various nursing staff, including a Corporate Quality Assurance RN and an MDS LPN, confirmed the absence of a hospice care plan and the lack of updates to the resident's care plan to address the actual skin impairments. The facility's policy on care plans, which emphasizes coordinated and resident-centered care, was not adhered to in this case. This deficiency was identified during an investigation under a specific complaint number.
Failure to Monitor Resident After Change in Condition
Penalty
Summary
The facility failed to appropriately monitor a resident after a significant change in condition related to signs of a urinary tract infection (UTI). The resident, who had a history of dementia, kidney disease, urinary retention, colon cancer, and malnutrition, was at risk for recurrent UTIs due to an indwelling urinary catheter. On 03/27/24, the resident exhibited poor fluid intake, dark yellow urine, and complaints of not feeling well. Although the physician was notified and an antiemetic was prescribed, there was no documented evidence of monitoring for fluid intake, urinary output, urine color, vital signs, or the resident's complaints until 04/01/24, when increased confusion and potential UTI were reported to the physician. Despite the physician's order for a urinalysis culture and sensitivity on 04/01/24, there was no documentation of when the urine sample was obtained and sent to the lab. The resident continued to be inadequately monitored until 04/05/24, when the physician was informed of the urine culture sensitivity results and prescribed an antibiotic for the UTI. The facility's policy required documentation of symptoms, assessments, physician orders, treatments, and follow-up monitoring when a change of condition was identified, which was not adhered to in this case.
Failure in Coordination of Care for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide proper coordination of care between hospice and facility staff for a resident, leading to a deficiency in pressure ulcer prevention. The resident, who was admitted to the facility and later to hospice, was at risk for pressure ulcer development but initially had no pressure ulcers. Despite physician orders for regular skin checks and preventive measures, new skin issues were identified by a hospice nurse, who informed the resident's family instead of the facility staff. This lack of communication resulted in the facility being unaware of the resident's skin issues until the family notified them. Upon assessment by the facility's Clinical Director RN and DON, two new skin areas were found on the resident's mid-back and one on the left heel, which were not previously documented by the hospice. The hospice notes lacked documentation of these skin issues, and the facility's care plans were not updated to reflect the resident's hospice care, skin impairments, or other conditions like groin swelling. Interviews with facility staff revealed that they were not informed of the new skin areas by the hospice nurse, and there was no documentation of communication between hospice and facility staff regarding the resident's skin condition. The facility's policy required a hospice agreement outlining collaboration of care, but this was not effectively implemented. The hospice nurse's failure to notify the facility of the resident's skin issues and the lack of a hospice care plan contributed to the deficiency. The facility's Corporate Quality Nurse confirmed the absence of adequate communication and care plan updates, highlighting a breakdown in the coordination of care between hospice and facility staff.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for two residents. For Resident #2, who had diagnoses including Alzheimer's disease, dementia, intermittent explosive disorder, and anxiety disorder, there was no documentation of complaints of hip or knee pain and possible rotation of the leg in the medical record. However, during the investigation of a self-reported incident, it was identified that Resident #2 had complaints of pain to the left hip and knee and a slight internal rotation of the left leg. The Corporate Quality Assurance Nurse confirmed that these concerns were not documented in the medical record, indicating an overall problem with documentation in the facility. For Resident #11, who had diagnoses including anxiety, major depressive disorder, difficulty in walking, and muscle weakness, the nurse aide task documentation for bed to chair transfers showed no refusals documented, despite 34 instances marked as not-applicable or not attempted. Interviews with staff confirmed that Resident #11 frequently refused to get out of bed, and these refusals were not documented accurately. The Corporate Quality Assurance Nurse verified that the facility had an overall problem with documentation, as refusals were not properly recorded in the nurse aide tasks.
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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 Canfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Austinwoods Rehab Health Care | 3.9 mi | ★★★★★ | 3 | 0 |
| Vista Center Of Boardman | 4.5 mi | ★★★★★ | 14 | 0 |
| Shepherd Of The Valley-boardman | 4.7 mi | ★★★★★ | 21 | 0 |
| Canfield Healthcare Center | 4.9 mi | ★★★★★ | 29 | 3 |
| Briarfield Manor | 5.4 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 June 2026) and official state health department websites.