Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Concord Care Center Of Toledo during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and well-maintained environment for multiple residents. One shared room had a large, visibly substandard ceiling repair from a prior water leak directly over a bed, along with additional wall damage, while the resident who used that bed typically remained there most of the day. A shared bathroom for four residents had water-stained doors, a broken light switch plate, a baseboard heater pulling away from the wall, and an unknown hardened material around the heater. In the same room and at two nurse stations, baseboard heaters and ceiling vents had heavy dust buildup, including dust drooping from a ceiling vent. The administrator and CNAs confirmed these conditions, which did not align with the facility’s policy for a safe, clean, and homelike environment.
Activities were not provided as scheduled for 62 residents on the first floor. The calendar listed morning activities, but observation showed activities were offered on the secured unit only, and a resident and another resident stated no morning activities were offered on the first floor. An AA confirmed the scheduled first-floor activities did not occur, despite the facility policy calling for an ongoing activities program based on resident assessment, care plan, and preferences.
Unsafe and unsanitary shower rooms were observed in two unit shower areas used by 55 first-floor residents. One shower room had a rusty wall heating source with holes and sharp edges, along with a rusty metal shower seat with sharp edges. Another shower room had about 19 missing tiles near the drain under the shower head, and standing water was observed. The ADM and Maintenance Director verified the findings, and the facility policy required a safe, clean, sanitary, and orderly environment.
Pest Control Failure on Secured Lower Level Unit: Gnats were observed throughout the secured lower level unit, including halls, common areas, and resident rooms. Two CNAs confirmed the infestation in resident areas, and two residents reported the gnats were bothersome and everywhere; three gnats were seen flying around one resident while she was lying in bed. The facility policy stated the Administrator or designee was responsible for ensuring adequate treatment for any existing infestation.
Surveyors found that the facility did not maintain a pest-free environment, with cockroaches, unidentified bugs, fruit flies, and house flies observed in resident shower and bathroom areas. Staff confirmed ongoing pest issues, water leaks, and water damage that contributed to the infestation, and a resident reported being bothered by the bugs.
Failure to Supervise Resident at Risk for Elopement: A resident with psychiatric diagnoses, cognitive impairment, and a known history of elopement was last seen returning from supervised smoking time and was later found missing from the facility. Staff initiated a missing resident response, but the resident remained unaccounted for until family contacted the facility and the DON and Administrator located the resident downtown. The resident reported being locked out after going out to smoke, and on return had redness and multiple blisters to both feet.
Unsafe, Unsanitary, and Unhomelike Resident Areas: Multiple resident rooms and shared bathrooms were observed in poor condition, including toilets with feces, urine, and toilet paper, foul odors, black substances on walls and windowsills, exposed wood, unsightly ceiling plaster, rusted and damaged door frames, and a jagged metal edge. Several rooms were also too warm, with temperatures documented at 77.9 to 81.9 degrees Fahrenheit, and residents or staff confirmed the conditions.
Call lights were found out of reach for three residents, including one resident with intact cognition and two residents with moderately impaired cognition. Observations showed the call lights tangled or placed underneath the beds, and an LPN and CNA verified they were not accessible. The facility policy states each resident is to have a means to call staff directly for assistance from the bed or bathing/toileting areas.
Failure to Report Resident Elopements as Alleged Neglect: Two residents eloped from their rooms and required facility searches and code brown responses. One resident with multiple psychiatric diagnoses and moderate cognitive impairment was later found miles away downtown, while another resident with schizoaffective disorder and other chronic conditions was found outside the building attempting to cross the street. No SRI was completed for either elopement, and the Administrator verified the incidents were not reported as alleged neglect.
PASARR screening was not completed or documented for two residents. One resident with dementia, schizoaffective disorder, and severe cognitive impairment had no PASARR results in the chart, and another resident with bipolar disorder, depression, and schizoaffective disorder required a level 2 PASARR that was not completed. HR verified both omissions, and the facility policy required PASARR completion for residents with intellectual disability.
Failure to provide grooming and personal hygiene assistance for a resident with severely impaired cognition and ADL deficits. The resident had a large amount of facial hair on her chin, said it bothered her, and reported staff had said they would shave her face if they had time; later observation showed the facial hair was still present, and a CNA confirmed it and said she would shave it. The resident’s MDS and care plan indicated she needed assistance with personal hygiene and staff intervention for self-care activities.
Failure to provide vision services and functional eyewear affected two residents. One resident with glaucoma and dementia had two broken pairs of glasses, and the DON confirmed there was no documentation of an eye doctor visit and the resident was not on the optometrist list. Another resident with multiple psychiatric and medical diagnoses said he needed glasses but no longer had them; staff and the DON confirmed he was not seen at the last eye doctor visit. Facility policy stated residents shall have access to vision services and adaptive equipment as indicated.
A resident with COPD, anemia in CKD, and dependence on supplemental O2 had an order for 2 to 3 L/min via NC PRN for SOB, but observations showed the oxygen concentrator running at 4 L/min via NC. An LPN verified the setting was 4 L/min and acknowledged the order was for 3 L/min via NC.
Failure to obtain ordered lab testing for a resident with glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. The resident had provider orders for lab work in January and June, but the June testing was not processed. The President of Clinical Services confirmed the ordered testing had not been completed, despite facility policy stating staff would arrange for ordered lab testing.
Failure to ensure access to dental services. A cognitively intact resident with multiple diagnoses, including schizoaffective disorder, bipolar disorder, and type 2 DM, had no teeth and stated he wanted dentures. The care plan noted missing natural teeth and referenced dental coordination, but the DON verified the resident had not seen the dentist and was not on the list to see the dentist. Facility policy stated it would assist with routine and emergency dental care, including appointments and transportation.
A resident’s record inaccurately documented participation in PT even though there were no PT orders on admission and no PT services had been initiated. The resident stated she was not receiving PT, the PT confirmed no PT had been provided, and the President of Clinical Services verified the charted notes were inconsistent with the orders and actual care.
Failure to Offer Influenza Vaccine After Readmission: A resident with multiple chronic conditions, including schizophrenia, COPD, CKD, DM2, and CHF, was documented as cognitively intact and had consent forms on file for the annual flu vaccine. Although the vaccine was initially marked refused, the ADON confirmed there was no evidence it was offered again after the resident returned from the hospital, and the resident stated she would want the annual influenza vaccine.
The facility failed to notify a physician about two residents not receiving their prescribed antipsychotic medication, Clozapine, as ordered. Both residents had complex medical histories, including schizophrenia and bipolar disorder, and missed several doses over a three-month period. The lack of medication administration was due to an incomplete Patient Services Form, and there was no documentation of physician notification regarding these missed doses.
Two residents in the facility did not receive their prescribed doses of Clozapine, an antipsychotic medication, due to issues such as medication being on back order and a mix-up in the REMS system. This led to one resident experiencing altered mental status and requiring emergency room evaluation. The facility failed to notify the physician about the missed doses, violating their medication administration policies.
Two residents in the facility did not receive their physician-ordered doses of Clozapine due to issues with the REMS system, pharmacy delays, and disorganization within the facility. Despite recorded deliveries, the medication was not administered as prescribed, affecting residents with complex medical histories.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 8.11%. Errors included administering an expired multivitamin, incorrect dosage of Lamictal, and omission of dorzolamide eye drops due to unavailability. The resident involved had intact cognition and was diagnosed with major depressive disorder and alcohol-induced dementia. The errors were observed during a medication administration session by an RN, who confirmed the mistakes and reordered the missing medication.
The facility failed to provide adequate behavioral health training for staff, necessary for caring for residents with mental and psychosocial disorders, including trauma and PTSD. Only one in-service session on de-escalation tips was conducted in the past year, which did not meet regulatory requirements. Several staff members did not receive any behavioral health training during orientation, and there were four self-reported incidents involving staff-to-resident interactions in the past six months. Staff expressed concerns about safety due to insufficient training.
A resident was subjected to physical and verbal abuse by CNAs in an LTC facility. The resident, who was cognitively intact, was pushed by a CNA, resulting in a fall and injuries. Another CNA verbally threatened the resident after a confrontation. The facility's policy on abuse was not upheld, and the incidents were not immediately reported.
A facility failed to timely report a verbal abuse incident where a CNA threatened a resident. The incident was not reported until three days later when a housekeeper discovered an audio recording. The resident was cognitively intact and had a complex medical history. The facility's policy requires immediate reporting of abuse, which was not followed.
The facility failed to maintain a safe and sanitary environment, affecting 30 residents on the first floor. Observations included mold-like substances, broken fixtures, and unsanitary conditions in various rooms and restrooms. Staff interviews confirmed awareness of these issues, which persisted despite the facility's policy for a homelike environment.
The facility failed to maintain a pest-free environment on the first floor, affecting 30 residents. Surveyors observed gnats and ants in various areas, confirmed by a CNA. Pest control documentation showed no evidence of addressing these issues, despite the facility's policy emphasizing the importance of pest control for resident safety.
The facility failed to maintain a clean and safe smoking area, affecting 40 residents who smoke. Observations revealed flammable booths with cigarette butts, improperly disposed cigarette waste, and trash around the area. A CNA confirmed these findings, indicating non-compliance with the facility's smoking policy, which requires staff supervision and safety measures. This issue represents continued non-compliance from a previous survey.
The facility failed to maintain a clean and safe environment, affecting eight residents and potentially all 77 residents. Observations included missing ceiling light covers, stained tiles, pulled carpeting, and dust accumulation. Exposed wires and holes in walls and ceilings were noted, along with missing bathroom fixtures. Shower rooms had foul odors and cracked tiles. The facility's policies emphasized the need for a clean environment, but these standards were not met.
A facility failed to maintain smoking safety when an STNA left seven residents unsupervised in a courtyard while they smoked. The STNA facilitated the smoking session but returned inside due to cold weather, leaving the residents unattended for about ten minutes. The facility's policy requires supervision during smoking, which was not adhered to, leading to a deficiency under Complaint Number OH00158800.
The facility failed to maintain a medication error rate below five percent, resulting in a 7.41 percent error rate. An LPN administered incorrect dosages of guaifenesin and fluticasone propionate to a resident, contrary to the physician's orders. Both the LPN and the resident were unaware of the correct dosages.
The facility failed to convey funds timely upon a resident's death and did not notify several residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. This affected six residents, with balances ranging from $1,830.36 to $3,772.96, and was confirmed by the Business Office Manager.
The facility failed to obtain written authorizations from residents or their representatives to open Resident Trust accounts, affecting three residents. The Business Office Manager confirmed the absence of written consents, despite the facility's policy requiring such authorization.
A resident with type II diabetes mellitus received the wrong type of insulin and at the wrong time. The LPN administered Novolog insulin instead of the prescribed Lispro insulin after the resident had already eaten breakfast. The facility's policy on safe and timely medication administration was not followed.
The facility failed to ensure medications were stored, labeled, and kept secure, affecting five residents. One resident accessed the medication storage room to assist an LPN, and an RN prepared medications for multiple residents simultaneously, violating facility policies.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, and adequately maintained environment for multiple residents. In one shared room, the ceiling above a resident’s bed had an approximately four-by-three-foot area of visibly substandard plaster repair from an apparent prior water leak, with unsanded spackling and partially painted areas, and additional water damage repairs on the outside wall. The administrator confirmed the poor-quality ceiling repair, and a CNA reported that one of the residents preferred to remain in bed under this area most of the day except for meals. In another shared bathroom used by four residents, surveyors observed water stains six to eight inches from the bottom of the door, a broken light switch plate, a baseboard heater detaching from the wall, and an unknown hardened sand-like material around and under the heater. A CNA confirmed that this bathroom was in disrepair. Further observations showed that the facility did not ensure a clean environment in resident rooms and common areas. In the same room with the ceiling repair, the baseboard heating vent had visible buildup of what appeared to be dust. At two nurse stations, ceiling vents had a thick layer of dust, with dust at one station drooping off the vent, and the baseboard heating vent at that station was coated inside and out with a thick layer of dust. The administrator verified these environmental and cleanliness issues. Review of the facility’s “Homelike Environment” policy, dated February 2021, showed that residents were to be provided a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting; however, the observed conditions did not meet these policy expectations.
Activities Not Provided as Scheduled
Penalty
Summary
The facility failed to implement the activities calendar as scheduled for 62 residents on the first floor, including residents #10 through #71, out of a census of 79. The February activities calendar scheduled Coffee Chat at 10:00 A.M. and Keep It Moving and Card Games at 10:30 A.M. on 02/24/26, but observations from 10:15 A.M. to 10:59 A.M. showed activities were offered to residents on the secured unit on the lower level and not to the 62 residents on the first floor. Resident #53 and an unidentified female resident stated during interview that no morning activities were offered on the first floor. The Activities Assistant stated that activities were offered to residents on the secured unit from 9:00 A.M. to 11:30 A.M. and to residents on the first level from 12:00 P.M. to 4:00 P.M., and verified that activities scheduled on the calendar for first-floor residents did not happen. The facility policy stated it would provide an ongoing program to support residents in their choice of activities based on comprehensive assessment, care plan, and preferences.
Unsafe and Unsanitary Shower Rooms
Penalty
Summary
The facility failed to maintain the shower rooms in a sanitary and safe condition for all 55 first-floor residents who used them. Observation of the Unit One shower room found an attached wall heating source that was rusty, had holes, and had sharp edges, and the shower area included a metal shower seat that was also rusty with sharp edges. Observation of the Unit Two shower room found approximately 19 missing tiles near the drain directly under the shower head, with the area lower than the drain and standing water present. The Administrator and Maintenance Director verified both shower room findings during interview. Review of the facility policy titled, Homelike Environment, dated February 2021, stated residents were to be provided with a safe, clean, comfortable, and homelike environment and that the facility should be clean, sanitary, and orderly.
Pest Control Failure on Secured Lower Level Unit
Penalty
Summary
The facility failed to ensure effective pest control on the secured lower level unit, where gnats were observed throughout the halls, common areas, and resident rooms during the survey. Staff interviews confirmed the presence of gnats in resident areas, with two CNAs verifying that gnats were throughout the secured unit. A resident stated the gnats in her room were very bothersome, and another resident stated the gnats were everywhere; during that interview, three gnats were observed flying around the resident while she was lying in bed. Review of the facility's Pest Control policy dated 06/19/24 showed the facility recognized the importance of pest and vermin control and stated the Administrator or designee was to ensure scheduled inspections provided adequate treatment for any existing infestation, with additional treatment as needed. The deficiency affected the 17 residents who resided on the secured lower level unit.
Failure to Maintain Pest-Free Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of cockroaches, unidentified bugs, fruit flies, and house flies in resident areas. Observations and staff interviews confirmed that the 100-hall shower room had a leaking toilet with towels placed around its base to contain water, which attracted bugs that were seen crawling from under the towel. The Housekeeping Supervisor acknowledged awareness of the pest issue, particularly in the 100-hall, and confirmed the presence of cockroaches and other pests. Additionally, a bathroom shared by four residents was found to have several fruit flies around the unsealed base of the toilet, on the ceiling, and near water pipes, with water damage to the ceiling contributing to the problem. Housekeeping staff confirmed the ongoing presence of these pests, and a resident reported being bothered by bugs in the bathroom. Further observations revealed that the water-damaged ceiling in the shared bathroom had hanging drywall paper and discoloration, and house flies were seen on a resident's clothing. The facility's pest control policy recognized the importance of pest and vermin control for resident health and safety, but the observed conditions demonstrated a failure to implement effective pest control measures. The deficiency had the potential to affect multiple residents who used the affected shower room and shared bathroom.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement. Resident #07, who had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, recurrent, post-traumatic stress disorder, obsessive compulsive disorder, kleptomania, and cognitive communication deficit, was identified in the care plan as being at risk for elopement due to psychiatric diagnoses, delusions, and a history of elopement. The resident’s MDS assessment showed moderate cognitive impairment. On 06/26/25, Resident #07 participated in the 11:00 P.M. supervised smoking time with three other residents. CNA #233 stated the resident was last seen when the group came back inside at about 11:15 P.M. Shortly afterward, staff discovered the resident was not in her bed, and a missing resident response was initiated. The facility searched the building, grounds, and surrounding area, but the resident was not located at that time. Resident #07 remained missing until 06/29/25, when the resident called a family representative for help and provided a location in the downtown area. The DON and Administrator found the resident standing on a corner with a bag in hand. The resident reported she had left the facility on foot, spent time downtown, rode a city bus, received food and clothing from a church, and had walked enough that her feet hurt. After return to the facility, the resident was assessed and found to have redness to the face and arms and multiple blisters to both feet, including the heels and toes. The resident also reported being locked out after going out to smoke and being unable to alert staff.
Unsafe, Unsanitary, and Unhomelike Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for multiple residents, including residents with cognitive impairment and mobility or self-care needs. Resident #28, who had paranoid schizophrenia, anxiety, hypertension, insomnia, and severely impaired cognition, was observed with a shared bathroom toilet containing urine, feces, and toilet paper accumulated to the height of the toilet seat. Feces were also on the back of the toilet seat, urine and an adult brief were on the bathroom floor, and a hole was present in the base of the bathroom door. Later the same day, the toilet again contained feces, toilet paper, and urine, and the resident’s bedroom had a strong foul odor. A CNA verified these conditions. Resident #37, who had generalized anxiety disorder, schizoaffective disorder, hypertension, and intact cognition, was observed in a bedroom with a black substance on the windowsill, an opened wall exposing wood with a black substance on it, and plaster applied to the ceiling in an unsightly manner. The resident stated the wall and windowsill bothered her because they were unsightly, and a housekeeper verified the exposed wood, black substance, and unsightly ceiling plaster. In another room shared by residents #31 and #4, the air conditioner cord was unplugged, the room felt warm, and the temperature measured 81.1 degrees Fahrenheit; the Administrator verified the unplugged cord and room temperature. Resident #6’s room also measured 81.9 degrees Fahrenheit, and the resident stated the room was always hot. Additional observations showed resident rooms and bathrooms with unsanitary and deteriorated conditions. In the room shared by residents #14 and #56, the temperature measured 77.9 degrees Fahrenheit, and resident #56 stated the room was always hot. Resident #65, who had heart failure, COPD, dysphagia, diabetes, and an oxygen order, told the Administrator her room was so hot and that she needed a cooler room; the room temperature measured 81.1 degrees Fahrenheit. Bathrooms shared by residents #16 and #35, and by residents #13, #27, #64, and #74, contained brown substances on toilet surfaces, rusty baseboards and door frames, and in one bathroom a missing section of door frame with a jagged rusted metal edge. Resident #27 stated the rust was unsightly and not homelike, and the DON verified the bathroom conditions.
Call Lights Out of Reach for Three Residents
Penalty
Summary
The facility failed to ensure residents could reach their call lights. During observation, Resident #51’s call light was found tangled underneath the bed and out of reach. Resident #51 was admitted on 01/21/21 and had diagnoses including borderline personality disorder, major depressive disorder, bipolar disorder, and insomnia. The quarterly MDS assessment noted intact cognition. An LPN later verified that the call light was tangled under the bed. Resident #69 and Resident #70 were also observed with their call lights underneath their beds and out of reach. Resident #69 was admitted on 03/14/25 and had diagnoses including schizophrenia, asthma, and major depressive disorder; the quarterly MDS assessment noted moderately impaired cognition. Resident #70 was admitted on 04/01/22 and had diagnoses including schizophrenia, major depressive disorder, and COPD; the quarterly MDS assessment also noted moderately impaired cognition. A CNA verified the call lights were underneath the beds and out of the residents’ reach. The facility policy titled Call System stated each resident is provided with a means to call staff directly for assistance from the bed or bathing/toileting facilities.
Failure to Report Resident Elopements as Alleged Neglect
Penalty
Summary
The facility failed to report incidents of resident elopement as alleged neglect for two residents reviewed for actual elopements. One resident had diagnoses including schizoaffective disorder bipolar type, major depressive disorder recurrent, post-traumatic stress disorder, obsessive compulsive disorder, kleptomania, and cognitive communication deficit, and was assessed as moderately cognitively impaired. Nursing documentation showed the resident was found missing from bed during the night, a code brown was called, the unit and facility were searched, the elopement protocol was initiated, and the resident was later returned after being located miles away in the downtown area. A second resident, with diagnoses including schizoaffective disorder depressive type, delusional disorders, mood disorder due to known physiological condition, chronic kidney disease stage 3, auditory hallucinations, hypertension, type 2 diabetes mellitus, schizophrenia, COPD, and systolic heart failure, was documented as cognitively intact. Nursing notes showed the resident was discovered missing during morning rounds, a code brown was called, and the resident was found outside in front of the building attempting to cross the street. Review of self-reported incidents showed no alleged neglect incidents were reported for either elopement, and the Administrator verified that no self-reported incident was completed for the resident elopements.
PASARR Screening Not Completed or Documented for Two Residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed or documented for two residents. One resident was admitted with diagnoses including dementia, cognitive communication deficit, schizoaffective disorder, chronic viral hepatitis C, and major depressive disorder, and the quarterly MDS showed severe cognitive impairment, but the resident’s chart did not contain PASARR results. A second resident was admitted with diagnoses including bipolar disorder, depression, schizoaffective disorder, and hypertension, and the quarterly MDS showed intact cognition, but the record indicated a level two PASARR was required and it was not completed. Human Resources verified that the PASARR results were not present in the first resident’s medical chart and that the level two PASARR had not been completed for the second resident. The facility policy stated that residents with an intellectual disability should have a PASARR completed to determine the level of services needed.
Failure to Provide Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide the necessary services related to grooming and personal hygiene for Resident #28, who had diagnoses including paranoid schizophrenia, anxiety, hypertension, and insomnia and was assessed as having severely impaired cognition. The resident’s MDS indicated she needed setup or clean-up assistance for personal hygiene, and her care plan stated that her functional abilities were impaired and that she required staff intervention to complete self-care and mobility activities. During observation, Resident #28 was noted to have a large amount of hair on her chin and stated that it bothered her; she reported that a staff person had told her they would shave her face if they had time. A later observation showed the facial hair remained unshaven, and a CNA confirmed the resident had a large amount of hair on her chin and stated she would shave it. The facility policy stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, including grooming and personal hygiene.
Failure to Provide Vision Services and Functional Eyewear
Penalty
Summary
The facility failed to ensure residents received services and equipment to adequately maintain vision for two residents reviewed for vision needs. Resident #62, admitted with diagnoses including glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder, stated he had two pairs of glasses that were both broken. Observation showed one pair of silver glasses missing the left temple arm and bent at the right temple arm, and a second pair of black glasses missing the left lens. The DON confirmed there was no documentation to show Resident #62 had seen an eye doctor and stated he was not on the patient list for the last facility eye doctor visit. Resident #09, admitted with diagnoses including schizoaffective disorder, bipolar disorder, muscle weakness, unspecified psychosis, essential hypertension, type 2 diabetes mellitus without complications, and muscle wasting and atrophy, was assessed as cognitively intact. The resident stated he previously had glasses but no longer had them and needed glasses. An LPN and CNA familiar with the resident stated they had not seen him with glasses, and the DON confirmed Resident #09 was not on the list to see the optometrist and did not see the eye doctor at the last facility visit. Facility policy stated all residents shall have access to hearing and vision services and receive adaptive equipment as indicated.
Oxygen Not Administered Per Physician Order
Penalty
Summary
The facility failed to administer oxygen per physician orders for Resident #37, who had diagnoses including chronic obstructive pulmonary disease, anemia in chronic kidney disease, and dependence on supplemental oxygen. The quarterly MDS assessment documented intact cognition. The physician order directed oxygen at 2 to 3 liters per minute via nasal cannula as needed for shortness of breath, but observation on 07/28/25 at 11:25 A.M. and again at 3:17 P.M. showed the resident's oxygen concentrator running at 4 liters per minute via nasal cannula. During interview on 07/28/25 at 3:22 P.M., LPN #276 verified the concentrator was running at 4 liters per minute and stated the physician order was for 3 liters per minute via nasal cannula. The facility policy titled Oxygen Safety stated licensed staff using oxygen will be trained upon hire regarding usage requirements.
Failure to Obtain Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain laboratory testing as ordered for one resident, Resident #62, who had diagnoses including glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. The medical record showed provider orders dated 05/08/25 for laboratory testing in January and June, but the June testing had not been processed. During interview on 07/31/25 at 12:00 P.M., the President of Clinical Services confirmed the resident had provider orders for laboratory testing to be completed in June and that the testing had not been processed. Facility policy titled "Lab and Diagnostic Test Results - Clinical Protocol" stated staff would arrange for ordered laboratory testing.
Failure to Ensure Access to Dental Services
Penalty
Summary
The facility failed to ensure residents had access to dental services. Resident #09, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, unspecified psychosis, essential hypertension, type 2 diabetes mellitus without complications, and muscle weakness/wasting, was cognitively intact on the most recent MDS. The care plan noted some or all missing natural teeth due to poor dental hygiene and stated the resident wore upper and lower dentures, with interventions to coordinate dental care and transportation as needed. However, the resident stated he had no teeth and wanted dentures, and observation confirmed he had no teeth. The DON verified the resident had not seen the dentist and was not on the list to see the dentist. The facility policy stated it would assist residents in obtaining routine and emergency dental care and, if necessary or requested, assist with dental appointments and transportation.
Inaccurate Documentation of Physical Therapy Services
Penalty
Summary
The facility failed to accurately document in the medical record for one resident. The resident was admitted with diagnoses including left-sided hemiplegia and hemiparesis following cerebral infarction, depression, anxiety, heart disease, and bone density disorders. Review of the medical record showed progress notes on multiple dates stating the resident participated in physical therapy, but provider orders showed there were no physical therapy orders on admission and no physical therapy orders had been initiated since admission. The resident stated she was not receiving physical therapy services, the physical therapist confirmed the resident had not received physical therapy, and the President of Clinical Services confirmed the progress notes indicated participation in physical therapy despite the absence of any physical therapy orders.
Failure to Offer Influenza Vaccine After Readmission
Penalty
Summary
The facility failed to offer the influenza vaccine as required for one resident reviewed for influenza vaccinations. Resident #13 was admitted with diagnoses including schizoaffective disorder depressive type, delusional disorders, mood disorder due to known physiological condition, chronic kidney disease stage 3, auditory hallucinations, essential hypertension, type two diabetes mellitus without complications, schizophrenia, chronic obstructive pulmonary disease, and unspecified systolic heart failure. The resident’s MDS assessment dated 06/04/25 indicated she was cognitively intact. Immunization documentation dated 10/14/24 showed the influenza vaccine was marked as refused, and the medical record also contained informed consent forms stating the resident provided consent for the facility to administer the influenza vaccine. The resident’s census documentation showed she was out to the hospital from [DATE] to 11/25/24, and the Assistant Director of Nursing stated the resident was manic when the influenza vaccine was offered in the fall and did not receive it. The ADON verified there was no evidence the vaccine was offered again after readmission. During interview, the resident stated she would want the annual influenza vaccine. The facility policy, Influenza Vaccine, dated March 2022, stated all residents and employees without medical contraindications will be offered the influenza vaccine annually.
Failure to Notify Physician of Missed Antipsychotic Medication Doses
Penalty
Summary
The facility failed to notify a physician about residents not receiving their prescribed antipsychotic medication, Clozapine, as ordered. This deficiency affected two residents, both of whom had complex medical histories including schizophrenia and bipolar disorder. Resident #36 was admitted with multiple diagnoses and had a physician's order for Clozapine 100 mg to be administered twice daily. However, the resident did not receive the medication on several occasions in November 2024, December 2024, and January 2025. The lack of medication administration was linked to an incomplete Patient Services Form in the Clozapine Risk Evaluation and Mitigation system, which prevented the pharmacy from dispensing the medication. Despite this, there was no documentation indicating that the physician was notified of these missed doses. Similarly, Resident #53, who also had a complex medical history including paranoid schizophrenia and psychosis, did not receive the prescribed doses of Clozapine on multiple occasions across November 2024, December 2024, and January 2025. The facility's records showed no evidence of physician notification regarding these missed doses. Interviews with the Regional Director of Clinical Services confirmed the medication was not administered as ordered and that there was no documentation of physician notification for either resident.
Failure to Administer Antipsychotic Medications as Prescribed
Penalty
Summary
The facility failed to ensure the mental health needs of two residents were met due to the improper administration of antipsychotic medications. Resident #36, diagnosed with schizophrenia and other conditions, did not receive her prescribed doses of Clozapine on multiple occasions across November 2024, December 2024, and January 2025. The lack of administration was due to issues such as the medication being on back order, not being available, or due to a mix-up in the Clozapine Risk Evaluation and Mitigation Strategy (REMS) system. This resulted in Resident #36 experiencing altered mental status and being sent to the emergency room for evaluation, where it was determined that her condition was due to not receiving her medications. Resident #53, with a diagnosis including paranoid schizophrenia and other conditions, also did not receive his prescribed doses of Clozapine on several occasions in November 2024, December 2024, and January 2025. The reasons for the missed doses included the medication not being available or on order. There was no documentation indicating that the facility notified the physician about the missed doses for both residents, which is a critical oversight in managing their care. The facility's policies on administering medications and handling medication errors were not adhered to, as evidenced by the lack of timely administration and physician notification. Interviews with staff, including the Regional Director of Nursing Compliance and the Director of Nursing, confirmed the deficiencies in medication administration and communication. The failure to administer medications as prescribed and to notify the physician of missed doses contributed to the deterioration of the residents' mental health conditions.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed, affecting two residents. Resident #36, who had multiple diagnoses including schizophrenia and bipolar disorder, did not receive her prescribed doses of Clozapine 100 mg on several occasions across November 2024, December 2024, and January 2025. The issues stemmed from a mix-up in the Clozapine Risk Evaluation and Mitigation Strategy (REMS) system, which prevented the pharmacy from dispensing the medication. Additionally, there were delays and back orders from the pharmacy, leading to missed doses. Resident #53, with a history of cognitive and emotional deficits, also experienced missed doses of Clozapine 100 mg and 200 mg during the same period. The facility's records indicated that the medication was not available on multiple occasions, and there were delays in receiving the medication from the pharmacy. Despite deliveries being recorded, the resident did not receive the medication as ordered, leading to further missed doses. Interviews with the Regional Director of Clinical Services confirmed the missed doses for both residents and highlighted disorganization within the facility due to changes in key staff positions, including the Director of Nursing and psychiatry provider. The facility's policy on administering medications, which mandates timely and safe administration, was not adhered to, resulting in this deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 8.11% during the observation period. This deficiency was identified through the observation of medication administration for three residents, with three errors specifically affecting one resident. The errors included the administration of an expired multivitamin, the failure to administer the correct dosage of Lamictal, and the omission of dorzolamide hydrochloride eye drops due to unavailability. The resident involved had intact cognition and was diagnosed with major depressive disorder and alcohol-induced dementia. The errors were observed during a medication administration session conducted by a registered nurse. The nurse confirmed the administration of an expired multivitamin and acknowledged the failure to administer the correct dosage of Lamictal, as only one tablet was given instead of the prescribed two. Additionally, the dorzolamide eye drops were not administered because they had not been reordered, which the nurse addressed by placing a refill order after the observation. The facility's policy on administering medications, which requires checking expiration dates and adhering to physician orders, was not followed, contributing to the identified deficiencies.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide adequate behavioral health training to its staff, which is necessary for caring for residents with mental and psychosocial disorders, including those with a history of trauma and PTSD. The facility's assessment indicated a need for staff competency in these areas, yet the only training provided in the past year was a single in-service session on de-escalation tips, which did not meet regulatory requirements. This session was attended by 25 employees, seven of whom are no longer employed at the facility. Additionally, a review of employee files revealed that several staff members, including CNAs, LPNs, and administrative personnel, did not receive any behavioral health training during their orientation. The deficiency was further highlighted by the fact that in the past six months, there were four self-reported incidents involving staff-to-resident interactions. Interviews with staff members, including CNAs and the Director of Nursing, confirmed the lack of adequate training, with some staff expressing concerns about their safety due to insufficient behavioral health training. The facility is currently working on establishing a crisis prevention and de-escalation/intervention training program, but as of the time of the report, no such program was in place.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by staff members. Resident #39, who was cognitively intact with a BIMS score of 15, was involved in an incident where a Certified Nursing Assistant (CNA) pushed him, causing him to fall. This incident occurred after Resident #39 was banging on the door of an employee restroom occupied by the CNA. Upon exiting the restroom, the CNA pushed the resident when he forcibly approached her, resulting in the resident falling and sustaining a skin tear on his left shin and a reddened face. The cause of these injuries was inconclusive, but it was suggested that they might have occurred when the resident was rolling on the floor or hitting the sink in his room. In addition to the physical abuse, verbal abuse was also reported. Another CNA threatened Resident #39 by stating, "if you spit on me, I will kick your [explicit term] teeth in," after the resident threatened to spit on her. This statement was verified by the CNA in a written statement. The facility's policy on resident abuse, neglect, and mistreatment emphasizes the right of residents to be free from verbal, sexual, physical, or mental abuse, yet this policy was not upheld in these instances. The incidents were not immediately reported to the facility, and the facility only became aware of the verbal abuse on November 4, 2024, and the physical abuse thereafter. The CNAs involved had participated in the facility's abuse, neglect, and exploitation training, yet the incidents still occurred. The facility's failure to prevent these incidents represents non-compliance with the standards for protecting residents from abuse.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged verbal abuse incident involving a resident. The incident occurred when a Certified Nursing Assistant (CNA) threatened a resident by stating, "if you spit on me, I will kick your [expletive] teeth in." This incident was not reported immediately as required by the facility's policy. The resident involved was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, and had a complex medical history including schizophrenia, bipolar disorder, and other mental health conditions. The verbal abuse was not reported to the facility until three days after the incident, when a housekeeper discovered an audio recording of the event on her phone. The housekeeper had overheard the incident but did not report it immediately. The facility's policy mandates that any alleged abuse must be reported immediately, but not later than two hours if it involves abuse or results in serious bodily injury. The delay in reporting the incident represents a failure to comply with this policy, affecting the resident involved and potentially impacting other residents in the unit.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff, affecting 30 residents on the first floor. During an environmental tour, several deficiencies were observed, including a blanket used as a curtain in multiple rooms, black mold-like substances in the shower room and resident restrooms, broken radiator covers, peeling paint, missing baseboards, and holes in walls and ceilings. Additionally, there were issues with exposed wires, broken outlet covers, missing soap dispensers, and toilet paper holders, as well as dried feces and unidentified brown substances in restrooms. Interviews with staff revealed that the foul odor in the first-floor shower room was persistent and emitted from the drain, and dried feces had been present in a shared restroom since November. The Regional Director of Operations acknowledged awareness of these environmental issues. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by the continued non-compliance from a previous survey and a complaint investigation.
Pest Control Deficiency on First Floor
Penalty
Summary
The facility failed to maintain a pest-free environment on the first floor, which had the potential to affect 30 residents. During a facility tour, surveyors observed approximately 15-20 gnats in the hallway, kitchen, and resident rooms, as well as ants in the resident restrooms. A Certified Nursing Assistant confirmed these findings. A review of the facility's pest control documentation from August to November revealed no evidence of addressing the issues with gnats and ants. The facility's Pest Control Policy emphasizes the importance of pest control in ensuring a safe living environment for residents.
Smoking Area Safety and Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain the smoking area in a clean and safe manner, potentially affecting 40 residents who smoke. During an observation tour, surveyors noted several safety and cleanliness issues in the smoking area, including four flammable restaurant-style booths with cigarette butts underneath, two metal ashtrays lined with aluminum foil, and a cigarette butt found in the seat of one booth. Additionally, a trash can containing cigarette butts and other trash was located next to the exterior wall of the facility, with more cigarette butts found under the edge of the wall. Leaves and trash were observed around containers holding trash and cigarette butts, and a towel on the ground was found with two cigarette butts nearby. A Certified Nursing Assistant (CNA) present in the smoking area with residents confirmed these findings. The facility's smoking policy, dated July 2023, states that smoking is only permitted during listed times with staff supervision, emphasizing safety. However, the observed conditions indicate non-compliance with this policy, as smoking without staff supervision is prohibited. This deficiency represents continued non-compliance from a previous survey conducted in October 2024.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, directly affecting eight residents and potentially impacting all 77 residents. Observations revealed several issues, including a missing ceiling light cover, stained and bowing ceiling tiles, and carpeting pulled away from the wall. There were dark brown streaks and black discoloration on furniture, stained carpeting, and spider webs and dust hanging from the ceiling. Additionally, a thick layer of dust was found on hallway vents, handrails, and fire alarm boxes. Missing ceiling tiles exposed wires and metal framing, and there were holes in the ceiling and walls in residents' rooms, with exposed and capped wires. Further issues included a missing toilet bowl tank cover, a bathroom door missing, and broken wall plates exposing wires. Three shower rooms had a foul musty urine odor, missing and cracked tiles, and a black substance on the tile and grout. The Housekeeping Supervisor and Maintenance Director verified these findings. The facility's policy on Resident Rights emphasized the right to a safe and clean environment, and the Facility Assessment stated that physical resources should meet residents' health and safety needs. The Daily Housekeeping Checklist required daily cleaning of resident rooms, bathrooms, and hallways, with specific attention to spots, stains, and dust removal.
Unsupervised Smoking Session in Courtyard
Penalty
Summary
The facility failed to ensure smoking safety was maintained for seven residents who were observed smoking in a fenced courtyard without supervision. On the morning of 10/28/24, a State tested Nursing Assistant (STNA) facilitated the smoking session by opening an exterior door, allowing the residents to enter the courtyard, handing each a cigarette, and lighting them. The STNA then returned inside the building, leaving the residents unsupervised while they smoked. This unsupervised smoking session lasted approximately ten minutes. Interviews conducted with the STNA and the Administrator confirmed that the residents were left unattended during the smoking session. The STNA admitted to leaving the residents unsupervised due to the cold weather. The facility's smoking policy, dated July 2023, mandates that residents must be supervised at all times during smoking, with no independent smokers allowed. The policy also specifies that smoking is only permitted during designated times and under direct staff observation. This incident represents a violation of the facility's smoking policy and was investigated under Complaint Number OH00158800.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 7.41 percent error rate. This was based on the observation of medication administration, staff interviews, record reviews, and policy reviews. Specifically, during an observation, an LPN administered 800 mg of guaifenesin to a resident instead of the prescribed 1,200 mg. Additionally, the same resident self-administered two sprays of fluticasone propionate in each nostril under the supervision of the LPN, contrary to the physician's order of one spray per nostril. Both the LPN and the resident were unaware of the correct dosage as per the prescriber's order. The deficiency was identified during a survey, which included a review of the facility's policy on administering medications. The policy, last revised in April 2019, stated that medications should be administered in accordance with prescriber orders. The facility census at the time was 76, and the error affected one of the three residents observed for medication administration. The deficiency was investigated under Complaint Number OH00153921.
Failure to Convey Resident Funds and Notify of Account Balances
Penalty
Summary
The facility failed to ensure timely conveyance of funds upon the death of a resident and did not notify several residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. Specifically, Resident #100 expired in the facility and had a balance of ninety-three dollars and thirty-six cents in their personal funds account, which was not conveyed to social security within the required 30 days. This was confirmed by the Business Office Manager during an interview. Additionally, five other residents had balances nearing or exceeding the state-allowed limit, but there was no evidence that spend down notifications were issued to them or their representatives as required. These residents had balances ranging from $1,830.36 to $3,772.96, and the lack of notification was verified by the Business Office Manager during interviews. The deficiency affected six of ten residents reviewed for funds conveyance and notices, with the facility census being 80. The Business Office Manager confirmed during interviews that there was no evidence of spend down notifications being sent to the residents or their representatives. This non-compliance was investigated under Complaint Number OH00152252, highlighting the facility's failure to adhere to regulatory requirements regarding resident funds management and notification procedures.
Failure to Obtain Written Authorization for Resident Trust Accounts
Penalty
Summary
The facility failed to obtain written authorizations from residents or their representatives to open Resident Trust accounts. This deficiency affected three residents, who had trust accounts with transactions recorded but no written consent on file. Specifically, Resident #3 had a trust account with a balance of $0.34, Resident #37 had a trust account with a balance of $0.36, and Resident #74 had a trust account with a balance of $228.72. In each case, the Business Office Manager confirmed that no written authorizations were available to show that the residents had authorized the facility to manage their trust accounts. The facility's policy requires written authorization from the resident or their representative before managing personal funds. However, the review of the medical records and quarterly statements for the three residents revealed that this policy was not followed. The deficiency was identified during an interview with the Business Office Manager and a review of the facility's admission packet and Resident Funds Policy and Procedure, which clearly state the need for written authorization to manage residents' personal funds.
Medication Administration Error
Penalty
Summary
The facility failed to ensure medications were administered to residents without significant medication errors. Specifically, Resident #77, who has type II diabetes mellitus and moderate cognitive impairment, was observed receiving the wrong type of insulin. The physician's order specified that Resident #77 should receive insulin Lispro before meals and at bedtime, but the Licensed Practical Nurse (LPN) administered Novolog insulin instead. Additionally, the insulin was administered after the resident had already eaten breakfast, contrary to the prescribed timing of administration before meals. The LPN acknowledged the error during an interview, stating that she was behind schedule and could not administer the insulin before the resident ate. The Director of Nursing confirmed that Novolog insulin is not the same as Lispro insulin and verified that the resident should have received Lispro insulin as ordered. The facility's policy on administering medications emphasizes that medications must be administered safely, timely, and as prescribed, which was not followed in this instance.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored, labeled, and kept secure at all times, affecting five residents. One incident involved a resident who was cognitively intact and admitted with schizoaffective disorder and bipolar disease. This resident entered the medication storage room and removed an orange medication box at the request of an LPN, which was against facility policy. The Assistant Director of Nursing and the Director of Nursing both confirmed that residents should not have access to the medication storage room. Observations revealed that the orange medication tote was unlocked and contained various stock medications, violating the facility's policy that only authorized personnel should have access to the medication room and its keys. Another incident involved improper medication administration practices by an RN. The RN prepared medications for two residents simultaneously, placing labeled medication cups on top of the medication cart and then transferring them to a bin in the cart's top drawer. This practice was observed during medication administration to two unidentified residents in the dining room, where medications were prepared ahead of time. The Assistant Director of Nursing confirmed that medications should be prepared and administered one resident at a time to prevent potential medication errors. The facility's policy mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in these instances.
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What surveyors actually found near you
We read the 595 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Foundation Park Care Center | 0.7 mi | ★★★★★ | 29 | 0 |
| Advanced Healthcare Center | 1.9 mi | ★★★★★ | 9 | 0 |
| Heatherdowns Rehab & Residential Care Center | 1.9 mi | ★★★★★ | 7 | 0 |
| Continuing Healthcare Of Toledo | 2.5 mi | ★★★★★ | 6 | 0 |
| Ohio Living Swan Creek | 2.7 mi | ★★★★★ | 17 | 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 July 2026) and official state health department websites.