Windsor House at Canfield: three years of state inspection reports
State inspectors cited the home twice for not properly reporting abuse allegations. ODH says there are no fines on file.
The issue
We got questions from the public about care at Windsor House at Canfield, a nursing home on State Route 446. Inspection reports are public. So we asked for all of them.
What we asked for
- Agency: Ohio Department of Health (PRI@odh.ohio.gov).
- Sent: October 21, 2026, 3:45 PM. ODH auto-acknowledged it 7 minutes later.
- Items, Jan 1, 2023 to date: (1) all inspection/survey reports (CMS-2567s) and plans of correction; (2) all complaints and how ODH handled each; (3) enforcement: fines, civil money penalties, admission bans, license actions; (4) self-reported incidents about wounds, infections, sepsis, neglect or deaths; (5) the current license and owner/operator records.
What we got
ODH answered the next day, October 22, 2026, 11:34 AM, and called the request closed. | Item | ODH's answer | |---|---| | 1. Surveys + plans of correction | Sent: 142 pages | | 2. Complaints | "No Responsive Records" | | 3. Enforcement | "No Responsive Records" | | 4. Self-reported incidents | "We do not maintain records in this manner" | | 5. License + ownership | Sent: 3 pages |
ODH's stated reason for not giving complaint records: its complaint system, ACTS, "is a federal database... not a public record," and under federal rules and two attached CMS memos (S&C 10-01 and S&C 11-39), "the records you are seeking other than the surveys are confidential as these documents belong to the Centers for Medicare and Medicaid Services." ODH told us to file a federal FOIA with "the CMS Chicago regional office" at this address: Office of the Attorney General, 500 S. 2nd Street, Springfield, Illinois, FOIAofficer@ilag.gov. (ODH email, Oct 22, 2026)
That's the Illinois Attorney General. Not CMS. Not Chicago.
ODH also noted that under R.C. 3721.02(F) these reports can't be used as evidence in most court cases. That limits lawsuits, not publishing.
What we found
(Page numbers are from ODH's 142-page "2567's.pdf." Residents and staff are numbered, not named, in the reports.)
1. Not reporting abuse to the state. Twice. - October 11, 2024: The facility "failed to timely report an allegation of physical abuse to the state agency." Two residents affected. (pp. 78-83) - January 8, 2026: The facility "failed to report to the state agency a resident to resident verbal abuse incident." Two residents affected. (pp. 101-107)
2. Wound care and records, again and again. - June 28, 2023: a significant medication error, plus a wound treatment not done/documented (records citation). (pp. 33-40) - February 2, 2024: a resident who needed two staff for care got one; the resident, who had a stage 4 pressure ulcer, rolled out of bed and went to the ER and was admitted. (pp. 45-50) - June 25, 2024: a resident on hospice care. Per the report, hospice documented new skin wounds that never made it to the facility's staff, the care plan wasn't updated, and signs of a urinary infection weren't monitored. The resident died April 26, 2024. (pp. 59-75) The citations were for care planning, quality of care and pressure ulcers, all at level "D." - August 19, 2026: tube-feeding and infection-control (enhanced barrier precautions) citations involving a resident with a pressure ulcer. (pp. 110-120)
3. Fire safety. The annual fire inspections in 2023 and 2026 found problems the reports rate as "widespread" (level F), including the sprinkler system in 2026. (pp. 121-130, 132-141)
4. No penalties. No fines, civil money penalties, admission bans or license actions appear in what ODH sent, and ODH says it has none (item 3). Every health citation in these reports is rated D or E. That means inspectors did not find "actual harm" or "immediate jeopardy" in the way the federal scale defines it.
5. Lots of complaints closed with "no deficiencies." Many complaint investigations from 2023 to 2026 are one-page forms marked in compliance. They don't say what the complaint was. (for example pp. 42-44, 77, 85-89, 109)
6. Who runs it. The 2026 license renewal lists the operator as Canfield Acres Company, LLC, with John J. Masternick as president, and a 96-bed capacity. ODH approved the renewal January 16, 2026, licensed through January 2027. (Licensing.pdf, pp. 1-3)
What's next
- ODH says it doesn't keep self-reported incidents "in this manner." So how do its own inspection reports cite "self-reported incident (SRI)" reviews? (for example pp. 53, 78-79, 101) Two of the citations are literally about incidents that should have been self-reported.
- Why did ODH send us to the Illinois Attorney General as the "CMS Chicago regional office"?
- Does ODH have any state licensing complaints or actions outside the federal system? Its answer only talks about the federal database.
- Gap in standard inspections? The annual health surveys we got are dated April 2023 and January 2026. Were there surveys in between that weren't sent, or none?
- Two failures to report abuse, a resident who died with wounds staff weren't told about, and zero fines. Is that how this is supposed to work?
Our opinion: A nursing home that's been cited twice for not reporting abuse to the state should at least get a phone call from somebody with a checkbook. We think the "no fines" part is the story.
Follow-ups
- We plan to reply to ODH on items 2-4 (self-reported incidents, state-side complaints, a written legal basis for each withheld record) and ask about the survey gap.
Documents
These are the records as the agencies released them. We blacked out only information that could identify a minor, our own personal contact details, and adult Social Security numbers. Any other black boxes were put there by the agency.
