Above average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Toledo Snf during CMS and state inspections, most recent first.
A cognitively impaired, wheelchair-dependent resident with multiple chronic conditions developed new, red, quarter-sized, symmetrical discoloration on both cheeks, identified during a skin assessment by an RN after prior documentation that the resident would not open her mouth for medications. The RN notified the DON, hospice, and the resident’s family, but no self-reported incident was filed and no investigation or report to the State Survey Agency was made. The DON stated she assumed the discoloration was self-inflicted based on the resident’s history of flailing, and the incident was not treated as an injury of unknown origin, contrary to the facility’s abuse prevention policy requiring such injuries to be reported and investigated.
Inaccurate wound assessment and delayed heel ulcer treatment: A resident with severe cognitive impairment and diagnoses including ESRD, aphasia, dysphagia, and adult failure to thrive returned from the hospital with preexisting buttocks and left heel wounds that were not described or measured on admission. A skin eval identified a suspected DTI to the left heel, but no wound tx was ordered right away, and the first order was not initiated until several days later. Heel protectors were ordered, yet an LPN found the resident in bed without them in place, and the DON and RN verified the admission skin assessment was inaccurate and the treatment orders were delayed.
A resident with ESRD, dysphagia, and severe cognitive impairment received hemodialysis, but pre/post dialysis communication reports were not completed on multiple occasions. The resident also had a documented 10-lb weight loss in 5 days, with no record that the physician was notified and no reweight documented at the time; the DON verified the missing reports and the lack of reweigh/notification.
Inaccurate transcription of medication hold parameters led to a MAR error for a resident with hypertensive heart failure, CHF, and atrial fibrillation. The MAR listed Losartan and Furosemide with hold instructions entered using the wrong greater-than and less-than signs, and the meds were administered per nursing judgement rather than as written. The DON verified the EMR orders were entered inaccurately and stated the orders may have been verbal.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an injury of unknown origin to the State Survey Agency as required by its abuse prevention policy. A cognitively impaired resident with diagnoses including COPD, heart failure, anxiety, depression, type 2 diabetes mellitus, and dementia was dependent for ADLs, used a wheelchair, and required assistance for transfers and mobility. Progress notes documented that on one day the resident would not open her mouth to take medications during two separate medication administration attempts. The following day, a progress note indicated the resident was assessed for discoloration on both sides of her face. A skin assessment completed by an RN described new discoloration on the bilateral sides of the resident’s face, located under the cheekbones, red in color, symmetrical, and approximately the size of a quarter, with notifications made to the DON, hospice, and the resident’s family. The RN later confirmed these characteristics in interview. Review of self-reported incidents showed there was no investigation initiated or report made to the State Survey Agency regarding this new bilateral facial discoloration. In interview, the DON stated she assumed, based on the resident’s history of flailing herself, that the discoloration was self-inflicted due to behaviors, and confirmed it was not reported or investigated as an injury of unknown origin, despite facility policy stating that suspicious injuries of unknown origin must be reported and investigated.
Inaccurate wound assessment and delayed heel ulcer treatment
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with pressure ulcers. The resident was admitted with diagnoses including end stage renal failure, aphasia following cerebral infarction, dysphagia, and adult failure to thrive, and was severely cognitively impaired per the MDS. On readmission from the hospital, the Nursing Admission/readmission Evaluation documented no new bruises or wounds, but also noted preexisting wounds on the buttocks and left heel without descriptions or measurements. The next day, the Skin Condition Evaluation identified a suspected deep tissue injury to the left heel measuring 1.4 cm by 3.2 cm by 0.0 cm, and there was no wound treatment ordered on the day of readmission or the following day. The first treatment order for the left heel was not initiated until five days later, when an order was entered to cleanse the wound and leave it open to air twice a day. A physician order for bilateral heel protectors was also entered, but observation later showed the resident lying in bed without heel protectors in place, and the protectors were found in the closet. The wound assessment reports documented the left heel DTI on 09/17/25 and again on 09/24/25, and the DON verified the admission/readmission evaluation was completed inaccurately because the resident had a new heel wound and there were no descriptions of the left heel and buttocks wounds. RN #360 also verified the skin assessment was completed with wound measurements and that no physician treatment orders for the left heel were implemented until five days later.
Missed dialysis monitoring and weight notification
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care and services for a resident who required hemodialysis. Resident #24 was admitted with end stage renal failure, dysphagia, and adult failure to thrive, and the MDS showed the resident was severely cognitively impaired and received dialysis. The care plan directed daily weights on Monday, Wednesday, and Friday and to notify the physician if weight gain was greater than three pounds in a day or five pounds in a week. Review of the pre/post dialysis communication reports showed they were not completed on 08/22/25, 08/27/25, and 09/12/25. The MAR showed the resident weighed 114.5 pounds on 09/17/25 and 104 pounds on 09/22/25, a 10-pound loss in five days, but there was no documentation that the physician was notified of the weight loss and no reweight document on 09/22/25. The DON verified the missing dialysis communication reports and verified the resident should have been reweighed and, if the weight was accurate, the physician should have been notified. The facility policy stated it would assure ongoing assessment and monitoring for complications before and after dialysis treatments and ongoing communication with the dialysis facility.
Inaccurate Transcription of Medication Hold Parameters
Penalty
Summary
The facility failed to ensure physician orders were transcribed accurately in the electronic medical record for one resident. The resident had an admission date of 02/01/23 and diagnoses including hypertensive heart failure, congestive heart failure, and atrial fibrillation. Review of the September 2025 MAR showed Losartan Potassium 25 mg daily for hypertension with hold parameters documented as hold for heart rate greater than 60, systolic blood pressure greater than 110, and diastolic blood pressure greater than 60, and Furosemide 10 mg daily for fluid overload with a hold parameter of heart rate greater than 60. The MAR also showed the medications were administered per nursing judgement and not as written in the order. The DON verified that the orders were entered inaccurately in the EMR, stating the Losartan should have been held if heart rate, systolic blood pressure, and diastolic blood pressure were under the specified values, and the Furosemide should have been held if heart rate was under 60. The DON also stated no written order was available and the orders may have been verbal orders from the physician, and that nurses used the greater than and less than signs incorrectly when entering the orders.
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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) |
|---|---|---|---|---|
| Arbors At Oregon | 1.3 mi | ★★★★★ | 9 | 1 |
| Orchard Villa | 1.6 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Oregon | 2 mi | ★★★★★ | 11 | 0 |
| The Gardens Of St. Francis | 3.3 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Point Place | 5.3 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.