Above 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 June 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.
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.
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 | ★★★★★ | 5 | 0 |
| Lutheran Village At Wolfcreek | 1.5 mi | ★★★★★ | 17 | 0 |
| Continuing Healthcare Of Toledo | 1.8 mi | ★★★★★ | 9 | 0 |
| Spring Meadows Nursing, A Villa Center | 2.2 mi | ★★★★★ | 10 | 0 |
| Foundation Park Care Center | 2.2 mi | ★★★★★ | 33 | 1 |
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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.