Winchester Terrace: Frayed Carpets and Filth Violations - OH
Someone filed a complaint. Inspectors came on September 18, 2025. What they found was documented under F0921, a citation covering the physical environment residents live in every day.
The deficiency covered many residents, according to the inspection report. Not one wing. Not one hallway. Many.
Winchester Terrace had its own policies on this. A document titled "Resident Right: Safe/Clean/Comfortable/Homelike Environment," dated September 3, 2024, stated the facility must provide exactly that: a safe, clean, comfortable, and homelike environment. A second policy, "Safe Environment," dated the same day, stated the facility will maintain its premises in a safe and sanitary manner.
The carpets told a different story.
Fraying carpet is a trip hazard for anyone. For nursing home residents, many of whom use walkers, wheelchairs, or unsteady legs to move through hallways, a raised or torn carpet edge is the kind of thing that ends with a fall and a fractured hip. Staining is a separate problem. In a facility housing people with incontinence, wounds, and illness, stained flooring near resident rooms and at the entrance to a soiled laundry room raises questions about what the stains are, how long they have been there, and whether the surfaces can actually be cleaned.
The inspection report does not answer those questions. It records what inspectors saw.
CMS rated the level of harm as minimal harm or potential for actual harm. That is the lower end of the scale, but it is not the bottom. It means the conditions inspectors documented were serious enough to cite under a complaint investigation, serious enough to affect many residents, and serious enough to put in writing that the facility had failed to do what its own policies promised.
The citation was tied to Complaint Number 2601158. Someone who knew what was happening inside Winchester Terrace contacted regulators. Inspectors arrived and confirmed it.
Facilities are not cited for having a single scuff on a baseboard. The standard for F0921 involves the overall environment residents must live in, and the inspectors who walked Winchester Terrace on September 18 found enough, in enough places, to write it up as affecting many residents.
The fraying carpet was outside a resident room. The stained carpet was outside resident rooms. The large stain was at the entrance to the soiled laundry room, a space that, by its nature, handles some of the most contaminated materials in the building. Whatever was tracked out of that room and into the carpet at its entrance had been there long enough to stain.
Winchester Terrace's own policy used the word homelike. That word carries weight in long-term care. For most residents, a nursing home is not a temporary stop. It is where they live, sometimes for years, sometimes until they die. The hallway outside their room is their hallway. The carpet they pass over in a wheelchair or shuffle across with a walker is their floor. A homelike environment, by any ordinary understanding of the word, does not have holes in the floor and fraying carpet and stains that have settled in enough to survive routine cleaning.
The inspection report does not say how long the conditions had existed before a complaint was filed. It does not say whether staff had flagged the carpet for repair and been ignored, or whether no one had noticed, or whether someone had noticed and decided it was not worth addressing. It records that the conditions were present when inspectors arrived, that they violated the facility's own written commitments, and that many residents were affected.
Those residents still live there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winchester Terrace from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WINCHESTER TERRACE in MANSFIELD, OH was cited for violations during a health inspection on September 18, 2025.
Inspectors came on September 18, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.