Average — CMS composite of the measures below.
A standard survey is most likely before around July 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 Arbors At Sylvania during CMS and state inspections, most recent first.
A resident with depression and a severe leg fracture was administered Seroquel 100 mg in error due to a transcription mistake during the admission process. The intended order was for sertraline 100 mg, but Seroquel was incorrectly entered and given. The error was discovered the following day during a medication review by an RN.
A resident with multiple medical conditions experienced significant, unaddressed weight loss, dropping nearly 20% of body weight over several months. Despite this, no interventions or assessments by the dietician or nursing staff were documented, and key staff were unaware of the issue. The resident reported insufficient food intake and dissatisfaction with meals, and facility policy requiring nutritional monitoring was not followed.
A resident with myasthenia gravis and multiple comorbidities did not receive nine doses of a physician-ordered medication, Pyridostigmine Bromide, due to the facility's failure to obtain and administer the drug after admission and following a hospital stay. The medication omission was not discovered until the resident was hospitalized, and both the physician and DON were unaware of the missed order until after the fact. Facility policy requiring timely administration and reporting of discrepancies was not followed.
A CNA was observed reusing face shields between resident rooms without disinfecting them and failing to perform hand hygiene before and after resident contact, including when entering a COVID isolation room. These actions were not in accordance with posted signage and facility policy, potentially affecting multiple residents.
A resident with severe cognitive impairment and a history of localized edema was repeatedly observed with dependent positioning of the arms and visible swelling, yet no interventions or care plans were documented or implemented to address the edema. Nursing staff confirmed the presence of pitting edema and the lack of any related interventions in the medical record.
A resident with severe contractures and impaired cognition did not receive physician-ordered interventions, including the placement of washcloths in both hands to prevent further contracture. Multiple observations and staff interviews confirmed that the washcloths were not in place as required, and the care plan was not consistently followed.
A resident with severe cognitive impairment and a history of falls did not have required fall prevention interventions, such as hipsters, consistently implemented. Despite care plan updates and staff awareness, observation confirmed the resident was not wearing hipsters as indicated, reflecting a failure to follow individualized fall management strategies.
A resident with heart failure and end stage renal disease, who was ordered to receive continuous oxygen at two liters per minute, was observed receiving oxygen at three liters per minute. An LPN confirmed the discrepancy between the physician's order and the actual oxygen flow rate, in violation of facility policy.
A resident with dementia, who was fully dependent for care, was found to have a privacy curtain in their room with several unidentifiable brown stains along the bottom. Observation and staff interview confirmed the stains, and facility policy required visibly dirty curtains to be cleaned or changed, which was not done.
A resident with significant medical needs and a history of pressure ulcers was not provided with a comfortable mattress despite repeated requests and a physician order for a low air loss mattress. The air mattress in use was partially inflated, causing discomfort, and staff did not attempt to obtain a replacement, even though they were aware of the resident's concerns.
Two residents who were always incontinent and dependent on staff did not receive timely incontinence care or repositioning, as required by their care plans and facility policy. Staff failed to check or change these residents at regular intervals, resulting in prolonged periods of soiling and the development of skin excoriation and rashes. Staff interviews and observations confirmed lapses in care and a lack of awareness regarding the timing of previous incontinence checks.
A resident with chronic pain and recent back surgery did not receive ordered non-pharmacological pain interventions, specifically ice packs, as part of their pain management plan. Despite physician orders and the resident's requests, ice packs were not routinely provided or documented, and the care plan lacked specific details about these interventions. Staff confirmed that non-pharmacological measures were only given upon request, and the DON acknowledged the absence of documentation and care plan inclusion.
Medication Transcription Error on Admission
Penalty
Summary
A deficiency occurred when a resident was admitted with diagnoses including depression and a severe left leg fracture. Upon admission, the community referral form did not include a physician order for the antipsychotic medication Seroquel 100 mg, but did include an order for the antidepressant sertraline 100 mg daily. However, a physician order for Seroquel 100 mg was incorrectly entered upon admission, and the medication administration record showed that Seroquel 100 mg was administered to the resident the morning after admission. The error was traced to a transcription mistake during the admission process, resulting in the resident receiving Seroquel 100 mg instead of the intended sertraline 100 mg. The incident was identified when a registered nurse reviewed the resident's medications the day after admission and discovered the error, by which time the incorrect medication had already been administered. The facility's policy required medications to be administered as ordered by the physician, but this was not followed due to the transcription error.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
A resident with multiple complex medical conditions, including myasthenia gravis, dementia, gastroparesis, and paraplegia, experienced significant weight loss over several months following admission. The resident's weight dropped from 165 lbs at admission to 133 lbs, representing a 19.39% decrease. Despite this notable weight loss, the medical record showed no evidence of interventions being implemented to address the issue, nor were there any progress notes or assessments by the dietician or nursing staff regarding the weight loss. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's weight loss. The DON was not aware of the situation, and the dietician, who is responsible for monitoring weights, did not know why interventions were not initiated. Although a therapy referral slip was completed by an LPN noting the weight loss, it is unclear if this information reached the dietician. The resident reported not receiving enough food and expressed dissatisfaction with the meals. The facility's policy requires maintaining residents' nutritional status, but this was not followed in the resident's case.
Failure to Administer Ordered Medication Due to Missed Order Entry and Oversight
Penalty
Summary
A deficiency occurred when the facility failed to obtain and administer a physician-ordered medication, Pyridostigmine Bromide, for a resident diagnosed with myasthenia gravis and other complex conditions. Upon admission, the resident had an active order for Pyridostigmine Bromide 30 mg three times daily, but the medication was not administered for a period spanning several days due to unavailability. The omission was not identified until the resident was admitted to the hospital, and upon return, the medication was reordered. Review of the Medication Administration Record showed that nine doses were missed between 05/30/25 and 06/02/25. Pharmacy documentation indicated the medication was delivered but returned due to the resident's hospital admission, and a subsequent delivery occurred days later. Interviews revealed that the physician was unaware of the medication order until after the resident's hospital stay, and the DON stated that nurses are responsible for entering medication orders upon a resident's return from the hospital, with unit managers conducting chart audits. The DON was not aware of the missed medication and believed the order was overlooked. Facility policy requires medications to be administered as ordered and discrepancies to be reported to the nurse manager, but this process was not followed in this instance.
Failure to Follow Infection Control Practices for PPE and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, as evidenced by multiple observations of a CNA reusing face shields between resident rooms without disinfecting them. The CNA donned and doffed PPE, including a face shield, when entering and exiting rooms on droplet isolation, but placed the used face shield back into the over-the-door organizer without cleaning it. The CNA also reused the same face shield for subsequent room entries without disinfecting it, despite bleach wipes being available for this purpose. Facility signage and policy required that reusable PPE such as face shields be disinfected or placed in a designated receptacle for reprocessing, but this was not followed. Additionally, the same CNA was observed failing to perform hand hygiene before and after entering resident rooms, including a COVID isolation room, and after removing PPE. The CNA delivered breakfast trays to residents without washing hands or using alcohol-based hand sanitizer, contrary to posted signage and facility policy, which required hand hygiene after PPE removal and between resident contacts. These lapses in infection control practices had the potential to affect 38 residents residing on the 100 and 200 hallways.
Failure to Initiate Edema Interventions for Dependent Resident
Penalty
Summary
The facility failed to implement interventions to address edema for a resident with a history of localized edema and multiple complex medical conditions, including anoxic brain damage, contractures, and chronic pain. The resident, who was dependent on staff for all activities of daily living and had severely impaired cognition, was observed multiple times with dependent positioning of the arms and hands, including visible edema and a closed fist in the left hand. Despite repeated observations and assessments by nursing staff confirming the presence of pitting edema in the left hand and forearm, there were no documented interventions in the medical record to address or monitor the edema. Staff interviews confirmed the absence of any care plan or interventions related to the resident's edema.
Failure to Implement Contracture Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent the deterioration of contractures for a resident with significant musculoskeletal impairments. The resident, who had diagnoses including anoxic brain damage, contractures in both hands, elbows, and shoulders, and chronic pain, was dependent on staff for all activities of daily living and had severely impaired cognition. The care plan included placing washcloths in both hands every shift to prevent fingers from clenching, cleansing and drying hands before application, and providing range of motion (ROM) as indicated. Despite these orders, multiple observations over several days revealed that the washcloths were not in place and the resident's hands remained closed-fisted. Staff interviews confirmed that the washcloths had not been applied as ordered, and the care plan interventions were not consistently followed. The resident was also noted to be unable to tolerate passive ROM due to distress, with care plans adjusted to clean hands as tolerated and monitor for skin breakdown. However, the primary intervention to prevent further contracture—placement of washcloths—was not implemented, as verified by both direct observation and staff acknowledgment.
Failure to Implement Fall Prevention Interventions as Indicated
Penalty
Summary
The facility failed to implement fall prevention interventions as indicated for a resident with multiple medical conditions, including severe cognitive impairment, mobility limitations, and a history of falls. Despite documented care plans and assessments identifying the need for specific interventions such as the use of hipsters, toileting and repositioning every two hours, and keeping the call light within reach, these measures were not consistently followed. Observation revealed that the resident was not wearing hipsters as required, and this was confirmed by an LPN at the time of observation. The resident had experienced multiple falls while attempting to ambulate to the restroom, and each incident resulted in updates to the care plan with new interventions. However, the lack of adherence to these interventions, specifically the failure to apply hipsters, demonstrated a lapse in the facility's responsibility to provide adequate supervision and implement individualized fall prevention strategies as outlined in their own policy.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with diagnoses of heart failure and end stage renal disease, who was care planned and ordered to receive continuous oxygen therapy at two liters per minute via nasal cannula, was observed receiving oxygen at a rate of three liters per minute from a portable tank. The resident was cognitively intact at the time of the incident. This discrepancy was confirmed by an LPN, who verified that the oxygen was running at a higher rate than prescribed and acknowledged the physician's order for two liters per minute. Facility policy requires oxygen to be administered only as ordered by a physician.
Failure to Maintain Clean Privacy Curtain in Resident Room
Penalty
Summary
The facility failed to maintain a clean environment in a resident's room by not ensuring the privacy curtain was free of visible stains. Observation revealed that the privacy curtain in the room of a resident with dementia, who was cognitively impaired and dependent for all care, had several unidentifiable brown stains along the bottom, extending approximately two feet in length. A CNA confirmed the presence of these stains. Review of the facility's policy indicated that privacy curtains should be changed or cleaned when visibly dirty, but this was not done in this instance.
Failure to Provide Requested Mattress Accommodation
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including cervical disc disorder with myelopathy, chronic venous hypertension with ulcers, COPD, diabetes, spinal stenosis, and a history of pressure ulcers, was not provided with a comfortable mattress despite repeated requests. The resident, who was dependent on staff for all activities of daily living and at moderate risk for skin breakdown, had a physician order for a low air loss mattress. Observations revealed that the air mattress in use was only partially inflated, causing the resident's buttock to rest against the bed frame. The resident reported having requested a new mattress several months prior, but no replacement had been provided. Staff interviews confirmed awareness of the resident's complaints regarding mattress comfort. Nursing staff were responsible for checking the mattress settings each shift and had determined the settings were appropriate. However, no attempts were made to obtain a replacement mattress, and the resident continued to experience discomfort. At the time of the survey, the resident had no current skin breakdown but did have scarring from previously healed wounds. The failure to provide a comfortable mattress following the resident's request constituted non-compliance with the requirement to reasonably accommodate resident needs and preferences.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The facility failed to provide timely and appropriate care for residents with bowel and bladder incontinence, as evidenced by observations, interviews, and medical record reviews. One resident, who was always incontinent and dependent on staff for all activities of daily living, was not checked or repositioned for extended periods. Despite care plans indicating the need for regular incontinence checks and repositioning, there was no documentation of specific intervals for these checks. Staff interviews revealed a lack of awareness regarding the timing of previous incontinence care, and direct observation found the resident heavily soiled with urine, with soiling extending to linens and wound dressings. Another resident, also always incontinent and dependent on staff, was observed to have developed excoriation and a rash due to inadequate incontinence care. The resident reported that staff were not providing the required two-hour checks and repositioning, which was corroborated by staff interviews and observations. The resident was found with excoriated skin, a large amount of urine, and a small bowel movement present, as well as two soiled incontinence briefs. Staff admitted to not having checked or changed the resident since assuming care and were unaware of the last time incontinence care was provided. Facility policy required that incontinent residents receive appropriate treatment and services, including regular checks and care to prevent infections and restore continence as much as possible. However, the lack of adherence to these policies, as demonstrated by the failure to provide timely incontinence care and repositioning, resulted in residents remaining soiled for prolonged periods and developing skin issues.
Failure to Provide and Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement and document non-pharmacological pain management interventions as ordered for a resident with a complex medical history, including cauda equina syndrome, spinal stenosis, chronic pain, and recent back surgery. Physician orders specified the use of ice packs to the surgical incision for pain relief multiple times daily, but the care plan did not detail these interventions, and administration records lacked documentation of their use. The resident, who was cognitively intact and able to express needs, reported not receiving non-pharmacological interventions such as ice packs between scheduled pain medications, despite repeated requests and physician instructions. Observations and interviews confirmed that the resident experienced significant pain and that ice packs were not provided as ordered, with staff indicating that the resident had to request them rather than receiving them routinely. The DON verified that the medical record did not reflect the provision of ice packs and that the care plan did not include this intervention. The facility's pain management policy required incorporation of pain interventions into the care plan and revision if pain was not adequately controlled, but these steps were not followed for this resident.
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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 Toledo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kingston Health Center Of Sylvania | 1.2 mi | ★★★★★ | 37 | 0 |
| Franciscan Care Ctr Sylvania | 1.9 mi | ★★★★★ | 27 | 1 |
| Rosary Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Lakes Of Sylvania, The | 3.4 mi | ★★★★★ | 9 | 0 |
| Spring Meadows Nursing, A Villa Center | 3.8 mi | ★★★★★ | 10 | 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.