Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Accura Healthcare Of Toledo during CMS and state inspections, most recent first.
A resident with severe dementia, known wandering behavior, and a history of entering others’ rooms was care planned with a wander alert bracelet and redirection, but continued to wander the halls and go into multiple residents’ rooms over several months. Documentation showed repeated nighttime wandering, difficulty finding his room, and an instance when his wander alarm was not functioning and no replacement was available. Several cognitively intact residents reported that he entered their rooms, at times sitting and watching TV, approaching their personal space, or removing his shoes and pants and asking to get into bed, while another resident with moderate cognitive impairment reported that he entered her room, kissed her on the lips, and attempted to lie in her bed. Staff and the administrator acknowledged that the resident had been wandering and entering rooms for an extended period and that, prior to the kissing incident, redirection was the only intervention used despite increasing behaviors.
Failure to complete required smoking assessments for a resident with severe cognitive impairment and dementia. The resident was identified as a smoker, had a care plan for supervised smoking and unsafe smoking practices, and progress notes documented smoking and complaints that she had been smoking in her room. The record contained one smoking assessment noting the resident needed a smoking apron and supervision, but lacked the additional assessments required by facility policy and expected by the DON and Administrator.
Failure to follow physician-ordered O2 settings for a resident with paraplegia, HF, and respiratory failure. The resident was observed using O2 via NC at 3 to 3.5 L instead of the ordered 2 L, while staff stated nurses and CMAs monitored O2 and O2 sats. The DON later found the cannister set above the ordered level, and the Administrator stated the facility did not have a policy for following physician orders.
Failure to Arrange Follow-Up Dental Care: A resident with intact cognition, paraplegia, HF, and respiratory failure had repeated tooth pain and needed help with oral hygiene. A visiting dental provider recommended extraction of six teeth after noting root tip pain, but the resident reported waiting for needed dental services, ongoing intermittent pain, and difficulty chewing, while staff said an outside dental appointment had only recently been arranged.
The facility failed to maintain proper dishwashing temperatures and food handling procedures. The dish machine did not consistently reach the required 120°F, and logs were incomplete. Staff handled ready-to-eat food with bare hands, violating policy. The Dietary Manager confirmed these issues.
A resident with intact cognition and respiratory failure was pressured by the DON to change his full code status during a health crisis, despite having previously discussed his wishes. The resident felt belittled, and staff confirmed the DON's unprofessional conduct, which contradicted the facility's policy on resident dignity and respect.
A facility failed to notify a physician of a hospital transfer for a resident with respiratory failure and did not follow oxygen orders for another resident with neurological conditions. The first resident was transferred to the ER without physician notification, and the second resident was observed using 4 liters of oxygen despite an order for 2 liters PRN. The facility lacked documentation and policies for these issues.
The facility inaccurately submitted staffing data to the CMS PBJ report, triggering a low weekend staffing alert for the 3rd quarter of 2024. The issue stemmed from not reporting all agency staff used on weekends, despite having adequate staffing according to their census. The Administrator noted that the corporate HR employee submits the data and that there is no formal policy for PBJ submissions.
A facility failed to document ongoing assessments for a resident with heart failure, hypertension, diabetes, and dementia after a change in condition was noted. The resident exhibited symptoms such as a sore throat, wet cough, and low oxygen saturation, but the clinical record lacked further assessments. The facility's Quality Assurance Nurse confirmed the absence of documentation, which is against federal guidelines and facility policies that require routine assessment and communication for changes in condition.
A facility failed to implement speech therapy recommendations for a resident with dementia and swallowing difficulties. Despite recommendations for a mechanical soft diet and supervision during meals, the facility did not document or follow these guidelines. Interviews with staff revealed a lack of awareness and communication regarding the speech therapist's recommendations, resulting in a deficiency in providing necessary rehabilitative services.
Failure to Adequately Supervise a Wandering Resident Who Entered Other Residents’ Rooms
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and supervise a cognitively impaired resident with known wandering and behavioral issues, resulting in repeated entry into other residents’ rooms and an incident of kissing another resident. The resident had a diagnosis of non-Alzheimer’s dementia, a BIMS score of 3/15 indicating severe cognitive impairment, and was independently ambulatory without a mobility device. His MDS documented wandering behaviors and daily use of a wander alarm. The care plan, initiated in November and updated in December, identified him as an elopement risk and documented behavior problems including urinating in inappropriate places, running up and down hallways, wandering into others’ rooms, and kissing another female resident. Interventions included use of a wander alert bracelet, calm redirection, removal from situations as needed, and monitoring and documenting behavior episodes to determine underlying causes. Clinical record review showed multiple documented episodes of wandering over several months, including difficulty finding his room, wandering throughout the facility at night, and going into different rooms. On one occasion in December, the wander alert device was documented as not functioning, and there was no replacement available in the facility, resulting in reliance on on-call staff monitoring. Between late March and late April, plan of care documentation recorded wandering on 15 shifts, with additional notations of grabbing, pushing, repeated movements, and one sexually inappropriate behavior. Staff interviews indicated that the resident had been wandering since admission, with increased wandering and following staff into other residents’ rooms in the weeks prior to the key incident, and that prior to that incident, redirection was the only intervention used when he entered other residents’ rooms. Multiple residents reported that this resident had entered their rooms or personal space. One cognitively intact resident reported that he had once gotten into her personal “bubble” but moved away when asked, and that she used a stop sign on her door because she did not like wanderers entering. Another resident stated he entered her room, looked out the window, and left without speaking or touching her. A different resident reported that he sat in her chair and watched TV on two occasions, leaving without physical contact but startling her. Another cognitively intact resident reported that he entered her room, removed his shoes, dropped his pants, and asked to get into bed with her; she and staff told him to leave, and nothing physical or sexual occurred. A resident with moderate cognitive impairment reported that he came into her room, kissed her on the lips while she was in a recliner, and then went to lie down in her bed; she activated or had her call light on and stated she was not scared and felt safe. Staff and the administrator acknowledged that the resident had been wandering and entering rooms for some time, that he had recently increased these behaviors, and that no new interventions beyond redirection were implemented between December and the incident in mid-April, despite awareness of his escalating wandering and entry into other residents’ rooms.
Failure to Complete Required Smoking Assessments
Penalty
Summary
The facility failed to complete smoking assessments for 1 of 1 resident reviewed for smoking, Resident #50. Resident #50’s MDS assessment showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and documented diagnoses of non-Alzheimer’s dementia and independent mobility. The care plan initiated on 8/12/25 identified the resident as a smoker with goals that she would not smoke without supervision and would not suffer injury from unsafe smoking practices. During the survey, the facility provided a list of residents who smoked, and Resident #50 was included. Progress notes showed the resident smoked on 8/24/25, 8/28/25, and 9/2/25, and on 10/8/25 Social Services spoke with her about complaints that she had been smoking in her room and obtained permission for the Administrator and Social Services to search the room for smoking materials. The clinical record showed a smoking assessment completed on 11/21/25 that indicated the resident required a smoking apron and supervision, but the record lacked additional smoking assessments. The facility policy required a smoking evaluation with care plan interventions upon admission, quarterly, annually, and with change in condition. The DON stated smoking assessments should have been completed with the resident’s MDS assessments, and the Administrator stated it was expected that residents have a smoking assessment completed prior to smoking at the facility.
Failure to Follow Ordered Oxygen Settings
Penalty
Summary
The facility failed to follow physician orders for oxygen use for Resident #37, who had a BIMS score of 14 out of 15 and diagnoses including paraplegia, heart failure, and respiratory failure. The resident’s care plan identified altered respiratory status and difficulty breathing related to a history of pulmonary embolism, acute and chronic respiratory failure with hypoxia, and heart failure. A physician order dated 5/30/25 directed oxygen at 2 liters per minute via nasal cannula every shift for acute and chronic respiratory failure. During observations on 1/5/26, 1/6/26, and 1/7/26, Resident #37 was seen lying in bed using oxygen via nasal cannula, but the oxygen cannister was set at 3.5 liters, 3 liters, and 3.5 liters instead of the ordered 2 liters. The resident stated he wanted to wean off oxygen and said the setting should be 2 liters. Staff interviews indicated nurses and CMAs monitored oxygen and oxygen saturation, and an LPN stated oxygen would be checked during the shift. The DON later observed the cannister set at 3.5 liters and turned it down to 2 liters, and the Administrator stated the facility did not have a policy for following physician orders.
Failure to Arrange Follow-Up Dental Care
Penalty
Summary
The facility failed to ensure follow-up dental care for a resident who had intact cognition, paraplegia, heart failure, respiratory failure, and required setup or clean-up assistance for oral hygiene. The resident’s record showed repeated complaints of teeth pain, with acetaminophen given on multiple occasions for tooth pain. A visiting Medicaid dental provider later documented that the resident had pain with root tips and recommended extraction of six teeth, and the provider also noted that the resident wanted the teeth extracted. The resident stated that several teeth had been lost since coming to the facility, that dental services had been needed but had been delayed, and that the resident continued to have intermittent pain and difficulty chewing, relying on soft foods because of the inability to chew in the back. The resident also reported being willing to go anywhere for the dental work and that the resident had continued to wait. Staff interviews reflected that an appointment with an outside dentist had only recently been arranged after the prior dental provider’s recommendations, and the facility policy stated it would assist residents in obtaining routine and emergency dental care.
Improper Dishwashing and Food Handling Procedures
Penalty
Summary
The facility failed to ensure that the dishwashing machine met the manufacturer's temperature guidelines for cleaning and sanitizing dishes. During an observation, it was noted that the American Dish Service low-temperature dish machine did not consistently reach the required minimum temperature of 120 degrees Fahrenheit for the wash and rinse cycles. The Dishwashing Record High Temperature log showed numerous instances where temperatures were recorded below the required levels, and many entries were left blank. Staff A, a Dietary Aide, was unaware of the correct temperature requirements and admitted to recording whatever the gauge displayed. The Dietary Manager confirmed the discrepancies and acknowledged the use of an incorrect log form for recording temperatures. Additionally, the facility failed to adhere to proper food handling procedures, as observed during a meal service. Staff C was seen handling ready-to-eat food items, such as hamburger buns and cheese slices, with bare hands, which is against the facility's policy. Staff D, while wearing gloves, used the same gloves to handle different food items and utensils, potentially leading to cross-contamination. Both staff members acknowledged their actions, and the Dietary Manager confirmed witnessing the improper handling of food. The facility's policies on cleaning dishes and food handling were not followed, contributing to the deficiencies observed. The Cleaning Dishes/Dish Machine Policy required verification of proper temperatures and chemical concentrations before use, which was not consistently done. The General Food Preparation and Handling policy prohibited bare-hand contact with ready-to-eat foods and required the use of clean utensils or gloves, which was also not adhered to during the observed meal service.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by the interactions between the Director of Nursing (DON) and Resident #33. The resident, who had intact cognition and was diagnosed with acute and chronic respiratory failure, had a full code/cardiopulmonary resuscitation (CPR) order in place. On the day of the incident, the resident contacted 911 due to health concerns, and emergency services were called to the facility. The DON insisted that the resident needed to go to the hospital because of his low oxygen levels and implied that he needed to change his code status if he chose to stay at the facility. This interaction was witnessed by emergency personnel and staff, who reported that the DON's approach made the resident feel small and was perceived as an ultimatum rather than a choice. Interviews with staff and the resident revealed that the DON repeatedly questioned the resident's code status, despite previous discussions, and suggested that the resident could not remain at the facility without changing his code status. The resident expressed feeling belittled by the DON's insistence on discussing his code status again. Staff members present during the incident corroborated the resident's account, noting that the DON's behavior was unprofessional and that she was asked to leave the room by emergency personnel. The facility's admission packet outlines the residents' rights to dignity and respect, which were not upheld in this situation, as confirmed by the facility administrator.
Failure to Notify Physician and Follow Oxygen Orders
Penalty
Summary
The facility failed to notify the physician of a hospital transfer for a resident with acute and chronic respiratory failure. The resident, who had intact cognition, was transferred to the emergency room due to a drastic change in mental cognition and low pulse oximetry. However, the clinical record lacked documentation of physician notification regarding the transfer. The Administrator acknowledged that there was no policy for physician notification and confirmed that the physician had not been notified at the time of the transfer. Additionally, the facility did not follow physician orders related to oxygen administration for another resident with multiple diagnoses, including progressive neurological conditions and anxiety disorder. The resident had an order for 2 liters of oxygen PRN for anxiety and low oxygen saturation, but was observed using 4 liters of oxygen on multiple occasions. The treatment administration record did not document the administration of oxygen or changes in tubing, and the Administrator and DON were unaware of the resident receiving oxygen at 4 liters. The facility lacked a policy on following physician orders, relying instead on professional standards.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing data for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the fiscal year 3rd quarter, covering April 1st to June 30th, 2024. The report triggered for excessively low weekend staffing, despite the facility having adequate staffing according to their census and facility assessment equation. The discrepancy arose because the facility did not accurately report the amount of agency staff used during weekends, with only three days of agency staffing submitted for the quarter. This inaccurate reporting led to the facility being flagged for low weekend staffing. The Administrator was uncertain about the cause of the low staffing trigger and noted that a corporate HR employee is responsible for submitting the PBJ data. The HR employee typically alerts the Administrator if there is low RN coverage, often due to omissions of agency staff or the DON/ADON who fill in for hours. The Administrator confirmed that the facility does not have a policy on submitting to PBJ, which may have contributed to the oversight. The facility has since been accurately reporting to PBJ, but the lack of a formal policy and the initial reporting errors led to the deficiency.
Failure to Document Ongoing Assessment After Change in Condition
Penalty
Summary
The facility failed to document ongoing assessments for a resident who experienced a change in condition. The resident, who had diagnoses including heart failure, hypertension, diabetes mellitus, and non-Alzheimer's dementia, was noted to have a change in condition on 8/3/2024. The resident's symptoms included feeling warm, a sore throat, a wet cough, and crackles in the upper lobes, with an oxygen saturation of 90% on room air. Despite these observations, the clinical record lacked documentation of further assessments following the initial report of the change in condition. The facility's Quality Assurance Nurse confirmed the absence of documentation and acknowledged that it is expected for nurses to adhere to federal guidelines and facility policies regarding documentation. The facility's policy on Clinical Change in Condition Management emphasizes the importance of daily observation and communication to identify changes in a resident's condition, which includes physical assessment, behavior, mobility, comfort level, and response to medications. However, the facility did not follow through with these procedures, resulting in a deficiency in documenting the resident's ongoing assessment after the change in condition was identified.
Failure to Implement Speech Therapy Recommendations
Penalty
Summary
The facility failed to provide adequate supervision and implement speech therapy recommendations for a resident diagnosed with Non-Alzheimer's Dementia, anxiety, depression, bipolar disorder, and weakness. The resident, who was edentulous and required setup assistance with eating, was identified as having nutritional problems related to dementia. The care plan included monitoring for signs of dysphagia and providing a calm setting during meals. However, the clinical record lacked documentation that the speech therapist's recommendations, which included a mechanical soft diet, distant supervision during oral intake, and cues for small bites and alternating solids and liquids, were followed. Interviews with facility staff, including the registered dietician, physician, and a registered nurse, confirmed that the speech therapist's recommendations were not communicated or implemented. The speech therapist had recommended a swallow study and discussed the risks of aspiration with the resident's Power of Attorney, who agreed with the resident's decision to remain on a regular solid diet. Despite this, the facility staff were unaware of these recommendations, leading to a deficiency in providing specialized rehabilitative services as required for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Toledo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny Hill Care Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Westbrook Acres | 15.2 mi | ★★★★★ | 8 | 0 |
| Sunrise Hill Care Center | 15.4 mi | ★★★★★ | 7 | 0 |
| Harmony Marshalltown | 16.2 mi | ★★★★★ | 18 | 0 |
| Accura Healthcare Of Marshalltown | 17 mi | ★★★★★ | 14 | 0 |
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