Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Ohio Living Swan Creek during CMS and state inspections, most recent first.
Food storage and hand hygiene deficiencies were observed in the kitchen and during meal service. Unlabeled and undated produce and cheese were found in the refrigerator, and an opened personal water bottle was stored in the freezer. During breakfast delivery, a CNA handled a resident's tray, touched an electric cord, left without hand hygiene, and then prepared and carried meal items for other residents without cleaning her hands.
Lack of Monitoring for Psychotropic Medications: The facility failed to document routine monitoring for effectiveness, side effects, and adverse effects for several residents receiving psychotropic medications, including antidepressants and antianxiety agents. Residents with diagnoses such as depression, dementia with mood disturbance, stroke, and cardiac conditions received medications including Zoloft, Buspirone, Lexapro, Lorazepam, Bupropion HCL, and Duloxetine, but the record contained no evidence of ongoing monitoring in the nurses’ notes, MARs, or TARs, and the DON confirmed the lack of documentation.
ABNs for three cognitively intact residents failed to include a specific estimated cost for non-covered skilled services. The notices stated Medicare may not pay for skilled services and listed room and board plus therapy at $5.00 a minute, but the DSS confirmed no dollar amount was entered on the forms, despite CMS instructions requiring an estimated total cost or daily, per item, or per service estimate.
The facility failed to keep care plans current for two residents. One resident had impaired cognition and developed an unstageable heel pressure ulcer and a DTI, but the care plan was not updated to reflect the current wound status. Another resident received PRN hydrocodone-acetaminophen, but the care plan did not address opioid use or monitoring for side effects such as constipation, delirium, oversedation, mental status changes, or reduced respiration.
Failure to provide adequate oral hygiene for a resident who required substantial/maximal assistance with oral care. The resident had dementia, anxiety, and HF, and staff observed an off-white sticky film between the lips and food buildup between the teeth. A CNA said the resident sometimes resisted oral care and that oral hygiene was not provided one morning because she was rushed and did not have time.
A resident with impaired cognition and a left heel pressure injury had ordered wound care and heel offloading measures that were not consistently in place. Staff observed the offloading boots not being used and the heels not being offloaded with a pillow, while the wound treatment was delayed because hydrogel was not in stock and the order was not placed in time. The wound progressed from a DTPI to an unstageable wound with slough, and staff documented that the resident was poorly compliant with offloading and had dementia/confusion.
A resident with pain, stroke, HTN, depression, and insomnia received an antidepressant and an opioid, but pharmacy recommendations were not reviewed or addressed by the provider. The pharmacist had recommended monitoring for behaviors with psychotropic use, changing the opioid order from scheduled to PRN, and monitoring for constipation, delirium, oversedation, mental status changes, and reduced respiration; the DON and UM confirmed these items were not implemented, and there was no evidence that recommended lab tests were completed.
Inappropriate antibiotic selection for UTI treatment. The facility failed to ensure appropriate antibiotics were used for two residents with UTIs. One resident received Macrobid even though one of the cultured organisms was resistant to it, and another resident received Cephalexin even though neither cultured organism was shown to be susceptible. The IP confirmed the culture results and noted the facility policy gave no guidance on ensuring an appropriate antibiotic was prescribed.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
Delayed Incontinence Care: A resident with severe cognitive impairment and bowel/bladder incontinence was found heavily soiled with urine and stool, with odor and saturation through the brief, Chux, and onto the bed linen. The CNA reported the resident was last checked early in the morning, refused care, and was not re-approached or reported to the assigned LPN, who was unaware the resident had gone without incontinence care for an extended period.
The facility failed to follow physician orders for catheter care for two residents. One resident did not receive the prescribed bacitracin ointment and split gauze for their suprapubic catheter, and another resident's urine output was not documented every shift as required. These deficiencies were identified through medical record reviews, observations, and staff interviews.
The facility failed to implement enhanced barrier precautions during catheter care for two residents. Despite specific physician orders and facility policies requiring the use of gloves and gowns, staff did not don gowns while performing catheter care. This was confirmed through observations and staff interviews.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store and handle food safely. In the main kitchen walk-in refrigerator, baby carrots and chopped celery were stored in plastic containers without labels or dates, and two opened bags of cubed cheese were also not dated. The stand-alone freezer contained an opened personal water bottle. The Assistant Dietary Manager verified that the carrots, celery, and opened bags of cubed cheese were not labeled or dated and confirmed the personal water bottle was in the freezer. The facility policy stated that leftover food should be stored in covered containers or wrapped securely and clearly labeled and dated before refrigeration. During breakfast service, a CNA delivered a tray to a resident who was in bed, raised the head of the bed, and rolled the overbed table across the resident's lap. The CNA then used her right hand to move an electric cord that was blocking the wheel of the overbed table, left the room without performing hand hygiene, and returned to the kitchen. She later obtained another resident's plate, covered it with plastic wrap, wrapped plastic silverware in paper napkins for two residents, and placed the items on a serving tray with another resident's breakfast plate already covered and waiting. The CNA then carried the serving tray to the hall and delivered one tray to a resident's room. She confirmed she did not perform hand hygiene after adjusting the resident's bed and touching the electric cord and before handling silverware for the other residents.
Lack of Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for four residents reviewed for unnecessary medications. Review of the medical record, staff interviews, pharmacist recommendations, and facility policies showed that residents receiving antidepressant and antianxiety medications did not have documentation of routine monitoring for medication effectiveness or adverse effects in the nurses’ notes, MARs, or TARs. Resident #13 was admitted with diagnoses including heart failure, respiratory disorders, depression, and sequelae of cerebral infarction. The resident had moderately impaired cognition, required staff assistance for all ADLs, and received Zoloft 100 mg daily. The record showed no orders for monitoring effectiveness, adverse effects, or side effects, and no documentation from 01/01/26 through 04/02/26 that the resident was monitored for the psychotropic medication. The DON verified there was no documentation of such monitoring. Resident #32 had diagnoses including cerebral atherosclerosis, moderate dementia with mood disturbance, atherosclerotic heart disease, and depression, and had severe cognitive impairment with staff assistance for all ADLs. The resident received Buspirone 7.5 mg three times daily, Lexapro 10 mg daily, and Lorazepam 0.5 mg every four hours as needed. Resident #38 was admitted for surgical aftercare and had diagnoses including muscle weakness, rectal prolapse, hemorrhage of the anus and rectum, and depressive episodes; the resident received Bupropion HCL extended release daily. Resident #5 had diagnoses including pain, stroke, hypertension, depression, and insomnia, had intact cognition, and received Duloxetine 60 mg daily. For each of these residents, the record showed no documentation that staff monitored for effectiveness, adverse effects, or side effects related to the psychotropic medications, and the DON confirmed the lack of documentation. The facility policy stated medication use is determined by evaluation of the resident’s physical, behavioral, mental, and psychosocial signs and symptoms, and the medication administration policy stated residents will be observed for adverse effects, contraindications, and medication effectiveness.
ABNs Missing Estimated Cost Information
Penalty
Summary
The facility failed to ensure beneficiary protection notifications included an estimated cost on the Advanced Beneficiary Notice of Non-coverage for three residents reviewed for this issue. Resident #11 was admitted with acute respiratory failure with hypoxia, acute on chronic diastolic heart failure, and chronic kidney disease, and was cognitively intact on the Minimum Data Set assessment. Resident #43 was admitted with dysphagia, essential hypertension, and ocular hypertension of the right eye, and was also cognitively intact. Resident #45 was admitted with acute osteomyelitis, cellulitis of the left lower limb, and type 2 diabetes mellitus with foot ulcer, and was cognitively intact as well. For each of the three residents, the ABN stated that Medicare may not pay for skilled services effective on a specified date and listed room and board plus therapy at $5.00 a minute, but did not include a specific dollar amount for the estimated cost. The Director of Social Services confirmed she did not include a dollar amount on the ABNs and stated she was not aware a specific dollar amount was required because room rates varied based on the room occupied. CMS SNF ABN instructions reviewed by surveyors stated the SNF should enter an estimated total cost or a daily, per item, or per service cost estimate and must make a good faith effort to insert a reasonable cost estimate for the care.
Incomplete Care Plans for Wounds and Opioid Monitoring
Penalty
Summary
The facility failed to ensure comprehensive care plans reflected each resident's individual needs and conditions for two residents reviewed. Resident #3 was admitted with diagnoses including cerebral atherosclerosis, psychosis, COPD, and CHF. The significant change MDS assessment showed impaired cognition, partial/moderate assistance with bed mobility, one unstageable wound, and one unstageable DTI. The care plan initiated after admission identified the resident as at risk for pressure ulcers, but it was not updated to reflect the resident's current status of having a left heel unstageable pressure ulcer and a right heel DTI documented on the weekly wound assessment. Resident #5 was admitted with diagnoses including pain, stroke, hypertension, depression, and insomnia. The quarterly MDS showed intact cognition and opioid use, and the physician order included Hydrocodone-Acetaminophen 10-325 mg every six hours as needed. A pharmacist recommendation to the physician noted monitoring for constipation, delirium, oversedation, mental status changes, and reduced respiration related to opioid use. However, the resident's care plan did not include a care area for opioid use or monitoring for opioid side effects. The MDS RN confirmed the care plan was not updated for Resident #3's wounds and confirmed Resident #5 did not have a care plan for opioid use or side effect monitoring.
Failure to Provide Adequate Oral Hygiene
Penalty
Summary
The facility failed to ensure dependent residents received adequate oral hygiene for one resident who required substantial to maximal assistance with oral care. The resident had diagnoses including dementia, anxiety, and heart failure, and the care plan noted the resident would resist personal care and medications, with interventions to re-direct and re-approach as needed. The quarterly MDS also documented impaired cognition and the need for substantial/maximal assistance for oral hygiene. During observation, the resident was seen sitting in a wheelchair in the common area with an off-white film between the upper and lower lips that stretched while speaking. Staff interviews confirmed the condition of the resident’s mouth, including a sticky film between the lips and food buildup between the teeth. A CNA stated the resident sometimes allowed oral care and sometimes kept the mouth closed, and that if brushing could not be done, a swab would be used; however, the CNA also stated oral care was not provided on one morning because she was rushed and did not have time. Another CNA stated washing the resident’s face earlier in the morning helped remove the film that was sometimes present between the lips.
Failure to Implement Wound Treatments and Heel Offloading
Penalty
Summary
The facility failed to ensure wound treatments were implemented timely and failed to ensure pressure ulcer prevention devices were in place for one resident reviewed for pressure ulcers. The resident was admitted with diagnoses including cerebral atherosclerosis, psychosis, chronic obstructive pulmonary disease, and congestive heart failure, and the comprehensive MDS showed impaired cognition, partial/moderate assistance needed for bed mobility, and the presence of an unstageable wound and an unstageable deep tissue injury. The care plan identified the resident as at risk for pressure ulcers, and the record showed a left heel deep tissue pressure injury was identified by facility staff and then assessed by the wound consultant. The resident’s physician orders included offloading heels with a pillow while in bed and later heel protector boots while in bed, with special instructions to use the green boot for the left foot. The left heel wound was followed weekly by the wound consultant and facility staff, and the treatment plan changed over time as the wound progressed from a DTPI to an unstageable wound with slough. On one assessment, the wound was noted to have opened to a dry layer of firmly adhered slough, and hydrogel was ordered; on a later assessment, the wound had declined and the provider documented that the resident was poorly compliant with offloading, had dementia/confusion, and that hydrogel gauze had not been received from the supplier. Observation showed the resident lying in bed with the offloading boots on the floor and the dresser at the end of the bed, and the resident stated she would wear the boots if offered. The RN confirmed the resident had orders for offloading boots and heel offloading with a pillow, but the heels were not offloaded and the boots were not in place. An LPN stated the facility did not have hydrogel in stock when it was ordered, that the NP was aware the order would not be implemented as written, and that no alternative treatment orders were provided until later while the facility was still awaiting delivery. The Administrator stated central supply orders were placed weekly and the hydrogel order was entered too late to meet the ordering timeframe, so it was not ordered until the following week.
Pharmacy Recommendations Not Addressed for Resident on Antidepressant and Opioid
Penalty
Summary
The facility failed to ensure pharmacy recommendations were reviewed and addressed by the provider for Resident #5. Resident #5 was admitted on 08/01/25 with diagnoses of pain, stroke, hypertension, depression, and insomnia. The quarterly MDS dated 03/30/26 showed intact cognition and use of an antidepressant and an opioid. Current physician orders included Duloxetine 60 mg daily and Hydrocodone-Acetaminophen 10-325 mg every six hours as needed. A pharmacist recommendation dated 10/02/25 instructed monitoring for behaviors with psychotropic use, changing Hydrocodone-Acetaminophen from scheduled every six hours to as needed every six hours, and monitoring for constipation, delirium, oversedation, mental status changes, and reduced respiration with opioid use. A facility document also referenced a pharmacist recommendation dated 12/2025 for laboratory tests. During interview on 04/02/26, the DON and Unit Manager confirmed the 10/02/25 recommendations were not reviewed or addressed by the provider and were not implemented, and the DON confirmed there was no evidence that the recommended laboratory tests were completed.
Inappropriate Antibiotic Selection for UTI Treatment
Penalty
Summary
The facility failed to ensure residents received appropriate antibiotics to treat urinary tract infections, affecting two of three residents reviewed for UTIs. Resident #26 was admitted with diagnoses including Parkinson's disease with dyskinesia, dementia, and UTI. A discontinued physician order showed the resident received Macrobid 100 mg by mouth twice daily for UTI. Review of the urine culture obtained to diagnose the infection showed growth of Klebsiella pneumoniae and Proteus vulgaris. The Unit Manager/Infection Preventionist confirmed Klebsiella pneumoniae was susceptible to Macrobid, but Proteus vulgaris was resistant to Macrobid, making the antibiotic ineffective against that organism. The review also showed both bacteria were susceptible to six other listed antibiotics. Former Resident #44 was admitted with diagnoses including sick sinus syndrome, presence of cardiac pacemaker, and flaccid neuropathic bladder, and had impaired cognition on the admission MDS. A discontinued physician order showed the resident received Cephalexin 500 mg by mouth twice daily. Review of the urine culture obtained to diagnose the UTI showed growth of Klebsiella pneumoniae and Proteus mirabilis, both at greater than 100,000 CFU/ml. The Unit Manager/Infection Preventionist confirmed Cephalexin was not listed among the antibiotics to which either organism was susceptible, so it could not be determined that the antibiotic was appropriate to treat the two bacterial infections. The facility policy on Antibiotic Stewardship provided no guidance regarding ensuring an appropriate antibiotic was prescribed to address bacterial infections.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure timely interventions were implemented to address incontinence for one resident. The resident was admitted with diagnoses including left humerus fracture, history of fall, rhabdomyolysis, muscle weakness, unspecified kidney injury, UTI, cerebral infarction, aphasia, CAD, atrial fibrillation, and CHF. The most current MDS assessment showed severe cognitive impairment, dependence on staff for ADLs, and incontinence of bowel and bladder. The nursing plan of care identified bladder incontinence related to needing assistance with toileting, transfers, and hygiene, with interventions to provide staff assistance for toileting, apply a moisture barrier, and provide incontinence care after each incontinent episode. During observation, the resident was found in bed heavily soiled with urine and a moderate amount of stool, with a pervasive urinary odor. The resident's urine and bowel incontinence had soaked through an adult brief and Chux pad and onto the bed linen, and the LPN UM stated the resident would require a complete bed change and bed bath. The CNA stated the resident was last checked for incontinence at 7:30 A.M., when the resident refused to get out of bed, and that the CNA did not inform the assigned nurse of the refusal. The CNA confirmed the resident had not been checked or re-approached for care since that time, and the LPN stated she was unaware the resident had not allowed incontinence care since 7:30 A.M.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters as per physician orders. For Resident #22, who had a suprapubic catheter due to urinary retention and a history of meatus erosion, the facility did not follow the physician's order for catheter care. The care plan required cleansing the catheter site with soap and water, applying bacitracin ointment, and covering it with split gauze every shift. However, during an observation, the RN did not apply bacitracin ointment or split gauze, and the RN later confirmed that these steps were not followed, despite the physician's order being documented as completed. Additionally, the RN noted slight redness and a bump at the catheter insertion site, indicating potential issues with the catheter care provided. For Resident #20, who was severely cognitively impaired and under hospice care, the facility failed to document urine output every shift as ordered by the physician. The resident had an indwelling catheter placed due to urinary retention, and the physician's order required catheter care and urine output documentation every shift. However, the records showed multiple instances where urine output was not recorded, and the Unit Manager confirmed that the documentation was incomplete. This lack of documentation could hinder the monitoring of the resident's condition and the effectiveness of the catheter care. The facility's policies on indwelling catheter care and physician orders emphasize the importance of following physician orders and monitoring urine output. However, the facility did not adhere to these policies, resulting in deficiencies in the care provided to residents with urinary catheters. These deficiencies were identified through medical record reviews, observations, and staff interviews, highlighting the need for improved compliance with physician orders and facility policies to ensure proper care for residents with urinary catheters.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions when providing catheter care to two residents, identified as Resident #20 and Resident #22. Resident #22, who had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and dementia, required a suprapubic catheter and had specific physician orders for enhanced barrier precautions. During an observation, a Registered Nurse (RN) did not don a gown while performing suprapubic catheter care, despite the care plan and physician orders specifying the need for gowns and gloves. The RN confirmed in a follow-up interview that a gown was not worn during the procedure, and the Unit Manager verified that enhanced barrier precautions were required for catheter care. Similarly, Resident #20, who had diagnoses including dementia and chronic obstructive pulmonary disease and was under Hospice care, required catheter care with specific orders for documentation of urine output every shift. During an observation, a State Tested Nursing Assistant (STNA) did not don a gown while performing catheter care, using only gloves. The STNA confirmed in an interview that gloves were the only personal protective equipment worn. The facility's policies on indwelling urinary catheter care and infection control required the use of gloves and gowns during catheter care, which were not followed in these instances.
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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) |
|---|---|---|---|---|
| Heatherdowns Rehab & Residential Care Center | 1.3 mi | ★★★★★ | 7 | 0 |
| Lutheran Village At Wolfcreek | 1.5 mi | ★★★★★ | 17 | 0 |
| Continuing Healthcare Of Toledo | 1.8 mi | ★★★★★ | 6 | 0 |
| Spring Meadows Nursing, A Villa Center | 2.2 mi | ★★★★★ | 10 | 0 |
| Foundation Park Care Center | 2.2 mi | ★★★★★ | 29 | 0 |
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