Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Continuing Healthcare Of Toledo during CMS and state inspections, most recent first.
Surveyors found that the facility failed to notify two residents’ representatives when the residents experienced significant changes in condition, despite a policy requiring such notification. One resident with multiple chronic conditions, mild cognitive impairment, and dependence for transfers developed chest pain and was sent to the ER without the POA being informed. Another resident with depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD developed abdominal pain, spasms, and audible wheezing, leading to imaging, labs, and medications being ordered, but again without POA notification. In both cases, the Administrator confirmed that the representatives were not notified.
Two residents who used oxygen, CPAP, and nebulizer treatments were found with respiratory equipment that was not maintained or stored in a sanitary manner. One resident’s room contained nasal cannulas on the floor next to an oxygen concentrator and a portable oxygen tank, none of which were dated, and a CPAP machine with undated tubing and an uncovered mask, contrary to facility policy requiring daily cleaning and bagging. Another resident’s nebulizer machine had tubing that was not dated. An LPN and a CNA confirmed these observations, and the DON acknowledged there was no policy for oxygen nasal cannulas or nebulizer tubing, despite stating that such tubing should be changed and dated weekly.
A resident with mild cognitive impairment and multiple chronic conditions was found with a medication cup containing several pills and an inhaler left on the bedside table without a nurse present. A CNA confirmed the medications were unattended, and an LPN acknowledged she was responsible for them and that residents are supposed to be observed when taking medications. Facility policies required that medications be either under the direct observation of the person administering them or locked in a medication cart, and that staff observe residents consuming medications, but these requirements were not followed.
A resident with severe cognitive impairment and total dependence for toileting did not receive timely incontinence care, resulting in saturated and soiled bed sheets, strong odors, and improper use of multiple incontinence products. Staff confirmed that care was not provided during the night, and facility policy requiring regular perineal care was not followed.
A resident with severe cognitive impairment and incontinence was found with a moldy water cup and soiled bed linens, while strong odors of urine and stool were present in the hallway. Staff confirmed lapses in cleaning and linen changes, and there was no documentation of water cup cleaning by dietary staff.
A resident with a suprapubic catheter did not receive consistent monitoring and care as required by physician orders and facility policy. Documentation was missing for daily cleansing and dressing changes at the catheter site, and urinary output was not consistently recorded. Observation confirmed the absence of a required dressing, and the DON acknowledged the lack of documentation for catheter site condition, treatment, and output.
The facility did not ensure that food and drink were served at safe and appetizing temperatures, resulting in multiple residents receiving cold and unpalatable meals. Staff and residents reported ongoing issues with food temperature and palatability, and direct observation confirmed that both hot and cold foods were served outside of safe temperature ranges. The Dietary Manager acknowledged these deficiencies, which affected several residents and had the potential to impact most individuals receiving meals from the kitchen.
Surveyors observed multiple areas of the facility that were not clean or well-maintained, including resident rooms with floor spots and wall scuffs, common areas with dirt and debris, hallways with cracked tiles and soiled walls, and a dining room with food spots, a cigarette butt, and debris. These conditions were confirmed by staff and did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with epilepsy, who was cognitively intact, refused three consecutive doses of their prescribed anti-seizure medication. The facility did not notify the physician as required by policy, and this was confirmed through medical record review and staff interview.
The facility failed to prevent skin breakdown in three residents with severe cognitive impairment and dependency on staff for daily activities. Observations revealed residents with double incontinence briefs, inadequate incontinence checks, and repositioning, contrary to facility policy. Care plans lacked specific frequency for these interventions, leading to potential risks for pressure ulcers.
The facility failed to provide timely incontinence care for three residents, all with severe cognitive impairment and always incontinent. Observations revealed residents with double briefs, contrary to facility policy, and a lack of documentation and communication between shifts. The DON confirmed that double briefing increases the risk of skin breakdown and infections.
A resident at risk for pressure ulcers experienced deterioration of an existing stage four ulcer and developed additional stage three ulcers due to the facility's failure to replace a broken ROHO cushion and implement alternative pressure-relieving interventions. Despite recommendations from a wound specialist, the resident remained in a wheelchair without necessary pressure relief, and staff were unaware of required wound care treatments, leading to untreated wounds and further skin breakdown.
The facility failed to maintain an effective quality assurance program, resulting in repeated deficiencies in providing ADL care to residents. Observations during the survey revealed a resident with dirty fingernails and another with long, jagged nails and heavy facial hair, indicating inadequate personal hygiene care. These issues were confirmed by staff interviews, highlighting a systemic problem in the facility's quality assurance processes.
The facility failed to maintain a safe and sanitary environment for its residents. A resident's room had a strong urine odor and exposed drywall, while another's room had soiled incontinence briefs and a dirty bathroom. A resident was observed in a wheelchair without an armrest pad, and two residents reported dirty air conditioning units and dusty window blinds. These conditions were confirmed by staff and violated the facility's policy on providing a safe, clean, and homelike environment.
The facility failed to ensure proper hand hygiene during meal service, affecting six residents. An LPN and an STNA were observed not performing hand hygiene between resident contacts while delivering meal trays. The STNA misunderstood the facility's policy, which requires hand hygiene between resident interactions.
The facility failed to accurately complete MDS assessments for two residents. One resident had a documented intact range of motion despite having a limited range in the left shoulder, confirmed by therapy reports and staff. Another resident's MDS assessment inaccurately documented a pressure ulcer instead of a trauma injury to the forearm. The DON confirmed these inaccuracies.
The facility failed to provide adequate nail care for two residents dependent on staff for ADLs. One resident with diabetes and anxiety had long nails with debris, despite being scheduled for nail care on bath days. Another resident with multiple disorders was observed with long, jagged nails and heavy facial hair. Staff interviews confirmed the lack of consistent nail care, indicating a deficiency in meeting personal hygiene needs.
The facility failed to follow physician orders for wound care and did not implement the bowel protocol for three residents. A resident with a forearm wound did not receive the prescribed daily dressing change, while two residents on pain medication did not receive necessary interventions for constipation despite prolonged periods without bowel movements. Staff interviews confirmed the lack of adherence to protocols, indicating systemic issues in care delivery.
The facility failed to supervise two residents while smoking and did not maintain smoking materials safely. One resident, with impaired cognition, was observed smoking unsupervised, while another resident had a half-smoked cigarette in his room despite being out at a doctor's appointment. Staff confirmed the lack of supervision and improper handling of smoking materials.
A resident with a history of incontinence was found heavily soiled with urine during a night shift, and the responsible STNA failed to provide necessary perineal care. The DON confirmed the resident required assistance with incontinence needs, but the facility lacked a specific policy for assessing bowel and bladder needs, despite having a perineal care policy.
A facility failed to follow enhanced barrier precautions for a resident with MRSA and a stage four pressure ulcer. An STNA did not wear a gown while providing incontinence care and carried an unbagged soiled brief through the facility. The resident's care plan required gown and glove use during high-contact activities, which was not adhered to, violating the facility's infection control policy.
The facility did not offer COVID-19 booster vaccines to three residents, as indicated by their medical records, which showed no education or consent for booster vaccines since their last administration in 2022. The DON confirmed the oversight, despite facility policy requiring vaccine offers and education when supplies are available, aligning with CDC guidelines for those aged 65 and older.
A facility failed to maintain an effective pest control program, resulting in gnats and house flies in a resident's room. The resident, with multiple health issues and impaired cognition, was observed with pests on bed linen and in the restroom. Staff confirmed the infestation, and the Maintenance Director was unaware and lacked documentation of pest prevention treatments.
The facility failed to ensure STNAs completed required training on dementia care and 12 hours of continuing education annually, potentially affecting all 61 residents. Personnel files for several STNAs lacked documentation of dementia care training, and interviews confirmed the absence of such training due to the facility not having a designated dementia unit.
Failure to Notify Resident Representatives of Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives of significant changes in condition, as required by facility policy. For one resident with multiple complex diagnoses including acute kidney failure, heart failure, stage three chronic kidney disease, symptomatic epilepsy, and obstructive sleep apnea, the quarterly MDS showed mild cognitive impairment, use of a walker and manual wheelchair, and a need for maximal assistance with transfers and moderate assistance with ADLs, as well as use of dialysis services. A progress note documented that this resident experienced chest pain and was sent to a local emergency room for treatment, but there was no documentation that the resident’s power of attorney (POA) was notified of this change in condition. In an interview, the Administrator confirmed that the POA had not been notified of this event. A second resident, admitted with depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, had a quarterly MDS indicating mild cognitive impairment, no behaviors or refusals of care, use of a manual wheelchair, dependence for transfers, independent mobility, and a need for moderate assistance with ADLs. A progress note documented that this resident experienced abdominal pain, spasms, and audible wheezing, and that imaging, labs, and medications were ordered in response. However, there was no indication in the record that this resident’s POA was notified of the change in condition. In an interview, the Administrator confirmed that the POA had not been notified. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” stated that the facility would notify a resident’s representative in the event of a significant change in condition, which did not occur for these two residents.
Failure to Maintain and Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The deficiency involves the facility’s failure to maintain and store respiratory equipment in a sanitary manner for two residents who used oxygen, CPAP, and nebulizer treatments. For one resident with multiple diagnoses including asthma, heart failure, chronic kidney disease, obstructive sleep apnea, and use of dialysis services, surveyors observed a nasal cannula lying on the floor next to an oxygen concentrator in the resident’s private room, with no label indicating the date it was initiated. A CPAP machine was also observed on the nightstand with tubing that was not dated and a mask that was not covered to protect it from dust and germs. Additionally, a portable oxygen tank was present with another nasal cannula on the floor that was also not dated. An LPN confirmed these observations and stated that oxygen and CPAP tubing should be dated, nasal cannulas should not be on the floor, and CPAP masks should be cleaned and bagged daily after use. The facility’s CPAP/BiPAP Cleaning policy required CPAP masks to be cleaned and dried daily after use and then stored in a plastic bag. For a second resident with diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, surveyors observed a nebulizer machine on the nightstand with tubing that was not labeled with the date it was initiated. A CNA confirmed that the nebulizer tubing was not dated. During an interview, the DON stated that the facility did not have a policy or procedure regarding the maintenance of oxygen nasal cannulas and nebulizer tubing, and further confirmed that oxygen nasal cannulas and nebulizer tubing should be changed and labeled with the date of initiation once weekly. This lack of policy and failure to follow existing CPAP cleaning and storage requirements resulted in respiratory equipment for both residents not being maintained and stored in a sanitary manner.
Unsecured and Unsupervised Medications Left at Resident Bedside
Penalty
Summary
Surveyors identified a deficiency in medication administration and storage involving one resident. The resident had diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, and a recent MDS assessment documented mild cognitive impairment, no behaviors or refusals of care, use of a manual wheelchair, dependence for transfers, independent mobility, and a need for moderate assistance with activities of daily living. During observation of the resident’s room, surveyors found a medication cup on the bedside table containing one green oblong pill, one white oblong pill, and four white round pills, along with an inhaler next to the cup. At the time of this observation, no nurse was present in the room. A CNA confirmed the presence of the medications and inhaler on the bedside table, and an LPN later confirmed she was the nurse responsible for those medications. The LPN also confirmed that residents should be observed consuming their medications when they are administered. Review of the facility’s “Medication Administration” policy stated that nursing staff administering medications should observe the resident consuming their medications. Review of the facility’s “Medication Storage” policy stated that medications would be under the direct observation of the person administering medications or locked in a medication cart. The unattended medications at the bedside, not under direct observation or secured, were identified as an incidental finding during a complaint investigation.
Failure to Provide Timely Incontinence Care and Maintain Cleanliness
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and total dependence for toileting and showers did not receive timely incontinence care. The resident, who was always incontinent of bowel and bladder, was observed to have a strong odor of urine and stool coming from their room. Upon further observation, the resident's bed sheets were found to be saturated with urine and soiled with stool, and the resident was wearing an incontinence brief with an additional brief used as a pad inside. Staff interviews confirmed that the resident's incontinence care products were saturated from the overnight shift and that care had not been provided during the night. The certified nurse aide reported that the stool was stuck to the resident's skin and that the bed sheets had not been changed during the morning care. The facility's policy required perineal care to be provided as needed to promote cleanliness, comfort, and prevent infection and skin breakdown. However, the care plan for the resident specified peri-care with each incontinence episode, and the Director of Nursing stated that briefs should be checked and changed every two hours. Despite these requirements, the resident did not receive timely incontinence care, and multiple incontinence products were used in a manner not consistent with standard practice. This failure affected one resident directly and had the potential to impact other residents identified as incontinent.
Failure to Maintain Cleanliness and Sanitation in Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by unclean water cups and persistent strong odors of urine and stool. One resident with severe cognitive impairment, functional bladder incontinence, and total dependence for toileting and showers was found to have a water cup on her dresser containing a black substance identified as mold, along with floating debris and film in the water. The resident was unaware of the location of her water cup, and staff confirmed the presence of mold. Dietary staff were responsible for cleaning water cups, but there was no documentation of cleaning practices. Additionally, a strong odor of urine and stool was observed in the hallway outside the same resident's room. The resident reported her incontinence brief had not been changed during the night, and staff confirmed that while her brief was changed in the morning, her bed sheets, which were saturated with urine and soiled with stool, had not been changed. Facility policy required a clean, sanitary, and comfortable environment, including clean bed linens and pleasant scents, but these standards were not met.
Failure to Maintain and Monitor Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to maintain and monitor a resident's urinary catheter system, specifically for a resident with a suprapubic catheter. The resident, who was admitted with multiple diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and a history of urinary tract infection, was dependent on staff for all activities of daily living and had a care plan that addressed some aspects of catheter care. However, the care plan did not include interventions to monitor the suprapubic stoma or to record the amount of urine collected in the catheter drainage bag. Physician orders required daily cleansing of the suprapubic catheter site and application of a dry dressing, but there was no documentation that this was performed on several specified dates. Additionally, there was a lack of assessment of the catheter stoma site in the medical record. Observation revealed that the resident did not have a dressing in place at the suprapubic insertion site as ordered. Electronic documentation also showed inconsistent recording of urinary output, with several shifts and days lacking any documentation of output. The facility's catheter care policy required catheter care every shift, regular changing of privacy bags, and emptying of drainage bags at specified intervals, but these practices were not consistently documented or observed. The Director of Nursing confirmed the lack of documentation regarding the catheter stoma condition, site treatment, and urinary output.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe, appetizing temperatures and were palatable, as required by both FDA guidelines and facility policy. Multiple residents who received meals in their rooms reported that their food was consistently cold and, in some cases, not palatable. Staff interviews confirmed that food delivered to resident rooms was typically at room temperature. During observation, a test tray revealed that hot foods, such as a fish sandwich, carrots, and green beans, were served below the recommended temperature of 140°F, with readings of 123°F, 110°F, and 108°F, respectively. The milk was also served above the safe cold temperature, at 53°F, and Jell-O was observed to be in a liquid state rather than properly set. The fish sandwich was described as cold, mushy, and overwhelmingly salty, making it unpalatable. Residents and staff consistently reported complaints regarding both the temperature and palatability of the food. The Dietary Manager acknowledged these concerns and verified the issues with the food's temperature and quality during the survey. The facility's own policy requires that residents receive nourishing, palatable, and well-balanced diets that meet their needs and preferences, but this standard was not met for several residents, with the potential to affect nearly all residents receiving meals from the kitchen.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, well-maintained, and homelike environment, as evidenced by multiple observations throughout the building. In one resident's room, there were large spots on the floor by the bed, scuff marks on the walls, and two gouges on the floor, each approximately three inches in diameter. The administrator confirmed these findings. In the common area of the 200-hall, dirt and debris were observed coating the floor by the nurse's station, which was also verified by the administrator. Additional observations included a hallway with eight cracked tiles, a wall soiled with an unidentified black substance near a resident's room, and another wall splattered with an unidentified brown substance next to a different resident's room. An LPN confirmed the presence of these issues. In the dining room of the 200-hall, there were 14 spots of unidentified food on the floor, a cigarette butt by the scale, and the floor under the air filter was coated with an unidentified black substance and debris. These findings were verified by staff interviews and were not in accordance with the facility's policy to provide a safe, clean, comfortable, and homelike environment.
Failure to Notify Physician After Multiple Medication Refusals
Penalty
Summary
The facility failed to notify the physician when a resident, who was cognitively intact and had a diagnosis of epilepsy, refused their prescribed anti-seizure medication, Keppra, for three consecutive doses. Medical record review showed that the resident refused both morning and bedtime doses on one day and the morning dose the following day, with no documentation indicating that the physician was informed of these refusals. Staff interview with the DON confirmed the lack of physician notification, and review of facility policy revealed that the nurse is required to notify the physician after two or more consecutive refusals of medication or treatment. This deficiency was identified during a complaint investigation.
Failure to Prevent Skin Breakdown in Residents
Penalty
Summary
The facility failed to provide adequate interventions to prevent skin breakdown for three residents, as observed during a survey. Resident #1, who had severe cognitive impairment and was dependent on staff for daily activities, was found with two incontinence briefs applied, contrary to facility policy. The resident was also missing an offloading boot, which was part of the care plan to prevent pressure ulcers. Documentation showed a lack of consistent incontinence checks and repositioning, which are critical for preventing skin breakdown. Resident #2, also with severe cognitive impairment and dependent on staff, was similarly found with two incontinence briefs and was soiled with urine. The staff was unaware of the last incontinence care provided, and there was a lack of documentation for repositioning and incontinence checks. The care plan did not specify the frequency for these interventions, which are essential for maintaining skin integrity. Resident #3, with severe cognitive impairment and at high risk for pressure ulcers, was found in a similar situation with two incontinence briefs and inadequate documentation of incontinence checks and repositioning. The facility's policies on pressure injury prevention and management were not followed, as evidenced by the lack of systematic documentation and adherence to care plans designed to prevent skin breakdown.
Failure to Implement Timely Incontinence Care
Penalty
Summary
The facility failed to implement timely and appropriate incontinence care interventions for three residents, as observed during a survey. Resident #1, who has severe cognitive impairment and is always incontinent of bowel and bladder, was found in bed with two incontinence briefs applied. The resident was unable to indicate when they were last checked for incontinence, and there was no documentation of incontinence checks after 9:23 P.M. the previous day. The CNA responsible for the resident at the time of observation had not received a report from the previous shift, and the Director of Nursing (DON) confirmed that double briefing is against facility policy due to the risk of skin breakdown and infections. Resident #2, also with severe cognitive impairment and always incontinent, was similarly found with two briefs and soiled with urine. The CNA on duty was unaware of the last incontinence check, and there was no documentation of checks after 11:48 P.M. the previous night. Interviews with staff revealed a lack of communication between shifts, with CNAs not providing reports to incoming staff. The DON reiterated the policy against double briefing and the requirement for CNAs to document incontinence checks. Resident #3, who is dependent on staff for all activities of daily living and always incontinent, was found with two briefs and no documentation of incontinence checks after 8:22 A.M. the previous day. The CNA on duty had not received a report from the previous shift, and the DON confirmed the facility's policy against double briefing. The lack of documentation and communication between shifts contributed to the failure to provide timely and appropriate incontinence care for these residents.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in the deterioration of an existing stage four pressure ulcer and the development of additional stage three pressure ulcers. The resident, who was at risk for pressure ulcers due to conditions such as paraplegia and diabetes, had a specialized ROHO cushion removed from their wheelchair for repair, and no alternative pressure-relieving intervention was implemented. This lack of intervention led to the resident developing two new stage three pressure ulcers and worsening of the existing stage four ulcer. The resident's medical record indicated a history of chronic stage four pressure ulcer on the right ischium, which was not healing as expected. Despite recommendations from a wound specialist to off-load the wound and use a specialized cushion, the facility did not replace the broken cushion or provide alternative pressure relief. Observations revealed that the resident remained in the wheelchair for extended periods without the necessary pressure relief, contributing to the skin breakdown. Interviews with staff, including a State Tested Nurse Aide and a Licensed Practical Nurse, revealed a lack of awareness and implementation of the required wound care treatments. The resident was found without dressings on their wounds, and there was a delay in applying the prescribed treatments. The Director of Nursing confirmed the absence of a pressure-relieving cushion and acknowledged the resident's inability to reposition themselves, which further exacerbated the situation.
Failure in Quality Assurance Program and ADL Care
Penalty
Summary
The facility failed to maintain an effective quality assurance program to address repeated quality concerns, as evidenced by deficiencies identified during three consecutive annual surveys. The CASPER Report dated August 2, 2024, highlighted deficiencies in providing activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022. This issue affected all 61 residents in the facility, indicating a systemic problem in the facility's quality assurance processes. Specific observations during the current annual survey revealed that Resident #24, who had intact cognition and was dependent on staff for personal hygiene, had dirty fingernails with dark debris under them on multiple occasions. Similarly, Resident #44, with moderately impaired cognition and dependent on staff for ADLs, was observed with long, jagged fingernails with black/brown debris and heavy facial hair growth. These observations were confirmed by staff interviews, indicating a failure to provide adequate personal hygiene care to these residents. The facility's policy on Quality Assurance and Performance Improvement (QAPI) stated that performance improvement activities should be monitored in QAA Committee meetings, but the repeated deficiencies suggest that these activities were not effectively implemented or sustained.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for its residents, as evidenced by several observations and interviews. Resident #36's room was found to have a strong urine odor, peeling paint, and exposed drywall, which was confirmed by both a Licensed Practical Nurse and the Maintenance Director. Resident #43's room was observed to have a foul odor, with soiled incontinence briefs, clothing, and linen on the floor, as well as a bathroom with soiled towels and toilet paper. A housekeeper verified the frequent soiled condition of the room. Resident #35 was observed multiple times seated in a wheelchair without an armrest pad on the left side, causing the resident's arm to rest on a thin pipe. A State-tested Nurse Aide confirmed the missing armrest and was unaware of its absence. Resident #46 reported dirt inside the air conditioning unit cover, which was confirmed by an observation that revealed dust rolling up from the filters. The Activities Director verified that maintenance was responsible for cleaning the air conditioning unit filters. Resident #47's air conditioning unit vents were coated with a brown substance, and the window blinds had a heavy buildup of dust. The resident stated that the facility had not cleaned the air conditioning unit in three years, although he had cleaned it himself once. An LPN confirmed the dirty condition of the air conditioning unit and window blinds. A housekeeper planned to deep-clean the room later in the day. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by these findings.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was practiced during meal service, affecting six residents. Observations revealed that a Licensed Practical Nurse (LPN) did not perform hand hygiene after assisting a resident with a wheelchair and before handling another resident's meal tray. The LPN confirmed the lapse in hand hygiene during an interview. Additionally, a State tested Nurse Aide (STNA) was observed delivering meal trays to multiple residents without performing hand hygiene between contacts. The STNA handled personal items and picked up a salt packet from the floor without cleaning her hands. During an interview, the STNA acknowledged not performing hand hygiene and misunderstood the facility's hand hygiene policy, which requires hand hygiene between resident contacts. The facility's policy review confirmed the requirement for hand hygiene between resident interactions.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for two residents. Resident #47, who was admitted with diagnoses of neoplasm of the brain and anxiety, had an annual MDS assessment indicating intact cognition and no functional limitations in the range of motion of the upper extremity. However, a physical therapy progress report and an updated therapy plan revealed that the resident had a limited range of motion in the left shoulder, from zero to 90 degrees, which was confirmed by the Rehabilitation Services Director. An interview and observation with the resident further confirmed the limited range of motion and associated pain. Resident #155, admitted with a diagnosis of a wound to the right forearm, had an MDS assessment indicating a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. However, a weekly wound evaluation and a skin observation tool indicated that the resident had a trauma injury to the right forearm. The Director of Nursing confirmed that the MDS assessments for both residents were documented incorrectly, highlighting inaccuracies in the facility's assessment process.
Inadequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for residents who were dependent on staff for assistance with activities of daily living (ADLs). Resident #24, who had diagnoses of type II diabetes mellitus and anxiety, was observed with long nails and dark debris under them on multiple occasions. Despite being dependent on staff for personal hygiene, her nails were not trimmed or cleaned as per her care plan, which indicated that nail care should be performed on bath days and as necessary. Interviews with staff confirmed that nail care was the responsibility of State Tested Nurse Aides (STNAs), but it was not consistently performed. Similarly, Resident #44, who had multiple diagnoses including schizoaffective disorder and vascular dementia, was observed with long, jagged fingernails with black/brown debris and heavy facial hair growth. This resident was also dependent on staff for ADLs, including personal hygiene. Staff interviews verified the observations of inadequate nail care. The facility's failure to ensure proper nail care for these residents highlights a deficiency in meeting the personal hygiene needs of residents who rely on staff assistance.
Failure to Follow Wound Care and Bowel Protocols
Penalty
Summary
The facility failed to adhere to physician orders for wound care and did not implement the bowel protocol as required, affecting three residents. Resident #155, who had a wound on the right forearm, did not receive the prescribed daily dressing change on 08/11/24, as confirmed by both the resident and LPN #426. The bandage was observed to be unchanged since 08/10/24, and there was no documentation of wound care on 08/11/24. Despite the wound showing improvement, the lack of adherence to the dressing change schedule was noted. For Resident #24, who was on narcotic pain medication, the facility failed to administer as-needed stool softeners despite the absence of documented bowel movements from 05/29/24 to 06/06/24. The facility's protocol required intervention after 72 hours without a bowel movement, but this was not followed. The resident expressed concerns about constipation due to pain medication, and the Director of Nursing confirmed the protocol was not implemented as it should have been. Similarly, Resident #49, who had a history of irritable bowel syndrome, did not receive additional interventions for constipation despite no documented bowel movements from 06/01/24 to 06/07/24. Although the dose of Senna S was increased, no further actions were taken according to the bowel protocol, which included administering Milk of Magnesia, suppositories, or enemas if necessary. Interviews with staff confirmed the lack of adherence to the bowel protocol, highlighting a systemic issue in monitoring and addressing bowel movements in residents.
Inadequate Supervision and Unsafe Maintenance of Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and safe maintenance of smoking materials for residents who smoke, affecting two residents. Resident #21, diagnosed with bipolar disorder, dementia, and schizophrenia, was observed smoking unsupervised in the designated smoking area. Despite requiring supervision due to impaired cognition, Resident #21 was seen smoking two cigarettes simultaneously, with ashes on his shorts and cigarette butts scattered around the area. Interviews with facility staff, including the MDS Coordinator and LPN, confirmed the absence of supervision and the requirement for Resident #21 to be supervised while smoking. Resident #156, with diagnoses of chronic obstructive pulmonary disease and hypertension, was found to have a half-smoked cigarette on a cardboard pizza box in his room while he was out at a doctor's appointment. Although Resident #156 was assessed as safe to smoke without supervision, the presence of smoking materials in his room was not in line with the facility's policy, which states that smoking materials for residents requiring supervision should be maintained by nursing staff. The LPN confirmed the observation of the cigarette in Resident #156's room.
Failure in Timely Incontinence Care and Perineal Hygiene
Penalty
Summary
The facility failed to provide timely incontinence care and interventions for a resident, identified as Resident #36, who was frequently incontinent of bowel and bladder. The resident, who had a history of multiple medical conditions including epilepsy, diabetes, and acute kidney failure, was found heavily soiled with urine during a night shift. The State tested Nurse Aide (STNA) #405, who was responsible for the resident during this shift, did not check the resident for incontinence and was unaware of the resident's incontinence history. Upon discovering the resident's condition, the STNA assisted the resident to the restroom but failed to provide necessary perineal care to cleanse the resident of residual urine before dressing them in clean clothing. The Director of Nursing (DON) confirmed that the resident required assistance with incontinence needs and that residents should be thoroughly cleansed following an incontinence episode. However, the facility lacked a specific policy or procedure to assess resident bowel and bladder needs, although a perineal care policy was in place to promote cleanliness and prevent infection. This deficiency in care was identified through observation, medical record review, and staff interviews, highlighting a lapse in the facility's adherence to its own care policies.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed during personal care for a resident with a stage four pressure ulcer and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The resident, who was dependent on staff for toileting and personal hygiene, had a physician order requiring staff to wear gowns and gloves during high-contact activities. Despite signage indicating the need for EBP, a State tested Nurse Aide (STNA) entered the resident's room and changed the resident's brief without wearing a gown, as required by the facility's policy. The STNA was observed carrying an unbagged soiled brief through the facility, past other resident rooms and the nurses' station, before disposing of it in the soiled utility room. The STNA admitted to not wearing a gown and carrying the brief unbagged because there was only one bag left in the resident's room. The Director of Nursing confirmed the resident's MRSA diagnosis and the requirement for EBP due to the infection in the resident's coccyx wound. The facility's policy mandates the use of gowns and gloves during high-contact care activities and requires soiled linens to be bagged at the bedside.
Failure to Offer COVID-19 Booster Vaccines
Penalty
Summary
The facility failed to offer COVID-19 booster vaccines to residents as indicated, affecting three residents out of five reviewed for COVID-19 vaccinations. The medical records for Residents #12, #15, and #34 showed that their last COVID-19 vaccination was administered on 08/19/22. There was no documentation of education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022 for these residents. An interview with the Director of Nursing confirmed that these residents were not offered COVID-19 vaccinations since 2022. The facility's policy, dated 05/23, stated that residents and staff would be offered the COVID-19 vaccine when supplies are available, and they would be screened for prior immunization, medical precautions, and contraindications. Education about the vaccine, including risks, benefits, and potential side effects, was to be provided before offering the vaccine. The CDC's updated guidelines recommend COVID-19 vaccination for everyone aged six months and older, with special considerations for those aged 65 and older to receive an additional dose of the updated vaccine.
Pest Control Deficiency in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an environment that was not free from pests. This deficiency was observed in the room of Resident #36, who was admitted with multiple diagnoses including epilepsy, type II diabetes mellitus, and acute kidney failure. The resident was assessed with moderately impaired cognition and required assistance with activities of daily living. Observations on two separate occasions noted the presence of gnats and house flies in the resident's room, including on the bed linen and in the restroom. During interviews, both a Licensed Practical Nurse and a State Tested Nurse Aide confirmed the presence of these pests in the resident's room. The Maintenance Director also verified the infestation but was unaware of the issue and could not provide documentation of any pest prevention treatments. This lack of awareness and documentation indicates a failure in the facility's pest control program, affecting the living conditions of Resident #36.
Deficiency in STNA Training on Dementia Care and Continuing Education
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) completed necessary training on dementia care and the required 12 hours of continuing education annually. This deficiency had the potential to affect all 61 residents in the facility. Specifically, the personnel file for STNA #409, hired on 09/20/18, lacked evidence of the required continuing education and dementia care training. Similarly, STNAs #479, #419, and #449, hired in 2023, had no documentation of dementia care training in their files. Interviews with the Human Resources Director and an STNA confirmed the absence of dementia training, with the HR Director noting that the facility did not provide such training due to the lack of a designated dementia unit.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Divine Rehabilitation And Nursing At Toledo | 1.7 mi | — | 28 | 0 |
| Foundation Park Care Center | 1.8 mi | ★★★★★ | 29 | 0 |
| Ohio Living Swan Creek | 1.8 mi | ★★★★★ | 17 | 0 |
| Concord Care Center Of Toledo | 2.5 mi | ★★★★★ | 6 | 0 |
| Heatherdowns Rehab & Residential Care Center | 2.5 mi | ★★★★★ | 7 | 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.