Concord Care Center of Toledo

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure the environment was adequately maintained. This affected six (#66, #67, #78, #79, #80, and #81) of six residents reviewed for environment. In addition, the facility failed to ensure a clean and comfortable environment. This affected 35 (#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) residents who resided on the Nurse Station One and Nurse Station Two halls. The facility census was 82.

Inspectors wroteBased on observation, staff interview, resident interview, review of the activities calendar, and review of the facility policy, the facility failed to implement the activities calendar as scheduled. This affected all 62 (#10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #71) residents who resided on the first floor of the facility. The facility census was 79.

Inspectors wroteBased on observation, staff interview, and review of the facility policy the facility failed to ensure the shower rooms were maintained in a sanitary and safe condition. This affected all 55 (#10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #23, #25, #26, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #63, #64, #65, #67, #68, #69, #70, and #71) residents residing on the first floor who utilized the shower room. The facility census was 79.

Inspectors wroteBased on observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure effective pest control. This had the potential to affect all 17 (#72, #72, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, and #88) residents who resided on the secured lower level unit of the facility. The facility census was 79.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure the facility was pest free. This had the potential to affect 29 residents (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43) who used the 100-hall shower. The facility identified one (#26) resident on the 100-hall who did not use the shower room. This deficient practice also affected four residents (#13, #44, #45, and #46) who shared a bathroom. The facility census was 78.1. Interview on 09/02/25 at 9:37 A.M. with Housekeeping Supervisor (HS) #501 confirmed she was aware of cockroaches and pests in the facility, particularly on the 100-hall. HS #501 stated the base of the toilet in the shower room on the 100-hall leaked and staff kept towels around the base of the toilet to contain the water. [...]

Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, resident interview, staff interview, review of the facility's investigation, and review of facility policy, the facility failed to provide adequate supervision to prevent resident elopement. Actual Harm occurred on 06/26/25 at 11:15 P.M. when Resident #07 eloped from the facility without staff knowledge. Resident #07 was missing until 06/29/25 at 3:45 P.M. when Resident #07 called the resident representative for assistance. This affected one (#07) of four residents reviewed for elopement. The facility identified 32 (#2, #4, #7, #11, #13, #15, #17, #20, #21, #22, #24, #26, #28, #34, #36, #37, #40, #42, #45, #52, #53, #56, #57, #60, #63, #65, #66, #67, #68, #69, #74, and #78) residents at risk of elopement. The facility census was 78. [...]

Inspectors wroteBased on record review, observation, staff interview, resident interview, and policy review, the facility failed to ensure a safe, clean, homelike environment. This affected 16 residents (#3, #4, #6, #13, #14, #16, #27, #28, #31, #35, #37, #56, #65, #58, #64, and #74) of 16 residents reviewed for a safe, clean, homelike environment. The facility census was 78. Review of Resident #28's medical chart revealed an admission date of 12/27/24. Diagnoses included paranoid schizophrenia, anxiety, hypertension, and insomnia. Review of the quarterly Minimum Data Sat (MDS) assessment dated [DATE] revealed Resident #28 had severely impaired cognition. Further review of the MDS assessment revealed Resident #28 needed setup or clean-up assistance for personal hygiene. [...]

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure residents could reach their call lights. This affected three residents (#51, #69, and #70) of three residents reviewed for call lights. The facility census was 78. 1. Review of Resident #51's medical record revealed an admission date of 01/21/21. Diagnoses included borderline personality disorder, major depressive disorder, bipolar disorder, and insomnia. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition. Observation on 07/28/25 at 9:52 A.M. of Resident #51's call light revealed the call light to be tangled underneath Resident #51's bed which was out of reach for Resident #51. Interview on 07/28/25 at 9:59 A.M. with Licensed Practical Nurse (LPN) #239 verified the call light was tangled under the resident's bed. 2. [...]

Inspectors wroteBased on medical record review, review of self-reported incidents (SRI), staff interview, and review of facility policy the facility failed to report incidents of resident elopement. This affected two (#7 and #13) of two residents reviewed for actual elopements. The facility census was 78. 1. Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included schizoaffective disorder bipolar type, major depressive disorder recurrent, post-traumatic stress disorder, schizoaffective disorder, obsessive compulsive disorder, kleptomania, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, 05/11/25, revealed the resident was moderately cognitively impaired. Review of nursing progress note, dated 06/27/25 at 12:30 A.M., revealed at approximately 12:30 A.M. staff notified the writer Resident #07 was not in her bed. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to obtain Preadmission Screening and Resident Review (PASARR) results for Resident #06. Furthermore, the facility failed to obtain a level two PASARR as indicated for Resident #21. This affected two residents (#06 and #21) of two residents reviewed for PASARR. The facility census was 78. 1. Review of Resident #06's medical record revealed an admission date of 01/14/25. Diagnoses included dementia, cognitive communication deficit, schizoaffective disorder, chronic viral hepatitis C, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #06 had severe cognitive impairment. Review of Resident #06's medical record revealed the results from the Preadmission Screening and Resident Review (PASARR) were not present in the chart. [...]

Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to provide the necessary services related to grooming and personal hygiene. This affected one resident (#28) of two residents reviewed for grooming and personal hygiene. The facility census was 78. Review of Resident #28's medical record revealed an admission date of 12/27/24. Diagnoses included paranoid schizophrenia, anxiety, hypertension, and insomnia. Review of the quarterly Minimum Data Sat (MDS) assessment dated [DATE] revealed Resident #28 had severely impaired cognition. Further review of the MDS assessment revealed Resident #28 needed setup or clean-up assistance for personal hygiene. Review of Resident #28's care plan dated 07/01/25 revealed Resident #28's functional abilities were impaired as well as a self-care and mobility deficit. [...]

Inspectors wroteBased on observations, staff interviews, resident interviews, and review of facility policy, the facility failed to ensure residents received services and equipment to adequately maintain vision. This affected two (Resident #09 and Resident #62) of two residents reviewed for vision. The facility census was 78. 1. Review of the medical record for Resident #62 revealed an admission date of 07/02/20. Diagnoses included glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. Interview on 07/28/25 at 9:35 A.M. with Resident #62 revealed he had two pairs of glasses that were both broken. Concurrent observation revealed one pair of silver glasses had a missing temple arm on the left side and were ill-fitting due to being bent at the right temple arm. A second pair of black glasses was missing the left lens. Interview on 07/31/25 at 12:25 P.M. [...]

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to administer oxygen per physician orders. This affected one resident (#37) of one resident reviewed for oxygen administration. The facility census was 78. Review of Resident #37's medical record revealed an admission date of 10/08/24. Diagnoses included chronic obstructive pulmonary disease, anemia in chronic kidney disease, and dependence on supplemental oxygen. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. Review of Resident #37's physician's orders revealed an order for oxygen at two to three liters per minute via nasal canula as needed for shortness of breath. Observation on 07/28/25 at 11:25 A.M. of Resident #37's oxygen concentrator revealed her oxygen to be running at four liters per minute via nasal cannula. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy the facility failed to obtain laboratory testing as ordered. This affected one (Resident #62) of one resident reviewed for laboratory testing. The facility census was 78. Review of the medical record for Resident #62 revealed an admission date of 07/02/20. Diagnoses included glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. Continued review of this medical record revealed provider orders dated 05/08/25 for laboratory testing in January and June. Interview on 07/31/25 at 12:00 P.M. with [NAME] President of Clinical Services #301 confirmed Resident #62 had provider orders for laboratory testing to be completed in June and the testing had not been processed. [...]

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to ensure residents had access to dental services. This affected one (#09) of two residents reviewed for dental services. The facility census was 78. Review of the medical record revealed Resident #09 was admitted on [DATE]. Diagnoses included schizoaffective disorder, bipolar disorder, muscle weakness, unspecified psychosis, essential hypertension, type two diabetes mellitus without complications, and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment, dated 06/23/25, revealed the resident was cognitively intact. Review of care plan, revised on 03/22/21, revealed Resident #09 has some/all missing natural teeth due to poor dental hygiene. The Resident wears upper and lower dentures. [...]

Inspectors wroteBased on medical record review, resident interview, staff interviews, and review of facility policy, the facility failed to accurately document in the medical record. This affected one (Resident #03) of one resident reviewed for accuracy of documentation. The facility census was 78. Review of the medical record for Resident #03 revealed an admission date of 06/03/25, diagnoses included hemiplegia and hemiparesis affecting the left side following cerebral infarction (stroke), depression, anxiety, heart disease, and bone density disorders. Further review of the medical record for Resident #03 revealed progress notes dated 06/03/25, 06/04/25, 06/06/25, 06/08/25, and 06/27/25 indicating Resident #03 participated in physical therapy. [...]

Inspectors wroteBased on medical record review, staff interview, resident interview, review of the admission packet and review of facility policy the facility failed to offer influenza vaccines as required. This affected one (#13) of five residents reviewed for influenza vaccinations. The facility census was 78. Review of the medical record revealed Resident #13 was admitted on [DATE] with re-entry on 11/25/24. Diagnoses included 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. Review of the Minimum Data Set (MDS) assessment, dated 06/04/25, revealed the resident was cognitively intact. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a physician was notiifed of a resident not receiving antipsychotic medications as ordered by the physician. This affected two (#36 and #53) of four residents reviewed for notification. The facility census was 79.

Inspectors wroteBased on record review, review of policies, review of hospital records, and staff interviews, the facility failed to ensure the mental health of a resident was met when antipsychotic medications were not administered per physician orders. This affected two (#36 and #53) of four residents reviewed for behavioral services. The facility census was 79.

Inspectors wroteBased on m medical records review, review of pharmacy records, and staff interviews, the facility failed to ensure that physician-ordered medications were available and administered per physcian orders. This affected two residents (#36 and #53) of four residents reviewed for pharmaceutical services. The facility census was 79.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to administer medications as ordered to ensure a medication error rate of not greater than five (5) percent (%). A total of three medication errors were observed out of 37 opportunities for a medication error rate of 8.11%. This affected one (#60) of three residents reviewed for medication administration. The census was 78.

Inspectors wroteBased on review of facility education documentation, review of facility assessment, review of employee files, review of self-reported incidents (SRI), and staff interview, the facility failed to provide adequate behavioral health training to care for residents with mental and psychosocial disorders. This had the potential to affect all residents residing in the facility. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, self-reported incident (SRI) review, witness statement review, employee file review, and policy review, the facility failed to ensure a resident was free physical and verbal abuse from staff. This affected one (#39) of eleven residents reviewed for abuse,with the potential to affect 49 of residents on Unit 1 and 3. The facility census was 80.

Inspectors wroteBased on record review, self-reported incident review, staff interview, and review of policy, the facility failed to timely report an alleged verbal abuse. This affected one (#39) of eleven residents reviewed for abuse, with a potential to affect 32 residents residing on Unit 1. The facility census was 80.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff. This had the potential to affect 30 (#7, #12, #13, #15, #17, #22, #24, #27, #29, #33, #34, #35, #40, #46, #47, #49, #50, #53, #54, #57, #62, #66, #67, #69, #70, #72, #74, #75, #78, and #79) residents, who reside on the first floor. The facility census was 80.

Inspectors wroteBased on observation, pest control report review, policy review, and staff interview, the facility failed to ensure the first floor was free from gnats and ants. This had the potential to affect 30 (#7, #12, #13, #15, #17, #22, #24, #27, #29, #33, #34, #35, #40, #46, #47, #49, #50, #53, #54, #57, #62, #66, #67, #69, #70, #72, #74, #75, #78, and #79) residents, who reside on the first floor. The facility census was 80.

Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to ensure the smoking area was maintained in a clean and safe manner. This had this potential to affect 40 (#2, #3, #4, #5, #6, #9, #11, #13, #15, #17, #18, #19, #21, #25, #26, #30, #36, #37, #38, #40, #41, #42, #44, #47, #48, #49, #54, #57, #58, #60, #61, #63, #64, #72, #73, #76, #78, #79, #80, and #81) who smoke. The facility census was 80.

Inspectors wroteBased on observation, staff interview, review of housekeeping check list, review of facility assessment, and review of policy, the facility failed to maintain a clean and safe environment. This directly affected eight (#16, #54, #55, #56, #63, #64, #65, and #90) residents with the potential to affect all 77 residents in the facility. The census was 77.

Inspectors wroteBased on observation, staff interview and review of policy, the facility failed to ensure smoking safety was maintained. This affected seven (#18, #31, #32, #33, #34, #37 and #38) of seven residents observed for smoking safety. The facility census was 77.

Inspectors wroteBased on observation of medication administration, staff interview, record review, and review of a policy for administering medications, the facility failed to ensure a medication error rate of less than five percent. 27 opportunities were observed with two medication errors, resulting in a 7.41 percent error rate. This affected one (Resident #15) of three residents observed for medication administration. The facility census was 76.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure funds were conveyed timely upon death for one resident (#100); and failed to notify five residents (#2, #4, #30, #51, and #71) when their personal funds account balance was within two hundred dollars of the state allowed limit. This affected six (#2, #4, #30, #51, #71, and #100) of ten residents reviewed for funds conveyance and notices. The facility census was 80. Findings Include: 1. Review of the medical record for Resident #100 revealed Resident #100 expired in the facility on [DATE]. Review of the resident account list dated [DATE] revealed Resident #100 had ninety-three dollars and thirty-six cents in the personal funds account. Interview on [DATE] at 2:00 P.M. [...]

Inspectors wroteBased on staff interview, record review, and review of the facility policy, the facility failed to obtain written authorizations by the resident or resident representative to open a Resident Trust account. This affected three (#3, #37 and #74) of ten residents reviewed for Resident Trust accounts. The facility census was 80.

Inspectors wroteBased on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure medications were administered to the residents without any significant medication errors. This affected one (#77) of five residents observed for medication administration. The facility census was 80.

Inspectors wroteBased on record review, resident and staff interview, observations, and review of the facility policy, the facility failed to ensure medications were stored, labeled, and kept secure at all times. This affected five (#34, #44, #63, and two residents who were not identified) of five residents reviewed for medication storage. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to notify the physician of unavailable treatment supplies for ordered wound care. This affected one (#8) of three residents reviewed for wound care. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to complete wound care treatments per physician orders. This affected one (#8) of three residents reviewed for wound care. The facility census was 80.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to ensure neurological checks were completely accurately after an unobserved fall. This affected three (#57, #66, and #84) of three residents reviewed for falls. Additionally, the facility failed to ensure neurological checks were completed after a resident alleged being struck in the head. This affected one (#85) of two residents reviewed for potential head injuries. The facility census was 80.

Inspectors wroteBased on record review, staff interview, and review of the staff schedule, the facility failed to ensure nurses charted and initiated physician orders with their own credentials. This affected one (#84) of one residents reviewed for an accurate medical record and had the potential to affect all other residents (#11, #17, #22, #33, #35, #37, #43, #49, #50, #58, #59, #69, #70, #74, #77,#80, and #91) on the first floor. The facility identified 18 residents on the first floor. The facility census was 80.

Inspectors wroteBased on observations, staff interviews, record review, review of the COVID-19 door postings, and review of the facility policy, the facility failed to ensure staff implemented infection control procedures regarding donning (putting on) and doffing (taking off) of Personal Protective Equipment (PPE) before entering and after exiting a room with an active case of COVID-19. This had the potential to affect 11 residents on the first floor who were not diagnosed with COVID-19 during the current outbreak (#17, #22, #35, #37, #43, #50, #59, #69, #70, #77, and #84). The facility census was 80.

Inspectors wroteBased on review of the medical record, staff interview, resident interview, review of the self-reported incidents (SRI), and policy review, the facility failed to ensure an allegation of verbal abuse was reported to the state agency. This affected one (#79) of three residents reviewed for abuse. The facility census was 80.

Inspectors wroteBased on medical record review, review of a Self-Reported Incident (SRI) investigation, review of a police report, staff interviews, and policy review, the facility failed to provide appropriate supervision to residents who were smoking. This resulted in actual harm when Resident #3 and Resident #8 were unsupervised in the smoking room when an argument took place leading to a physical altercation, causing Resident #3 to sustain a bruised left eye and a broken finger. This affected two (Residents #3 and #8) of three residents reviewed for resident-to-resident altercations. The facility census was 81.

Inspectors wroteBased on observation, staff interview, review of the dishwasher manufacturer manual, review of an email from the chemical supplier, review of food temperature logs, and review of facility policy, the facility failed to ensure foods were properly labeled and stored, failed to ensure the milk cooler was monitored for appropriate cooling temperature, failed to maintain food temperature logs, failed to ensure the dishwasher properly sanitized dishes, and failed to maintain a clean and sanitary kitchen. This had the potential to affect all 80 residents of the facility. The facility census was 80.

Inspectors wroteBased on observation, staff interview, and review of facility policy the facility failed to ensure effective pest control was maintained. This has the potential to affect all residents residing at the facility. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents wishes for life-sustaining treatment was clearly reflected in the medical record. This affected nine (Residents #18, #19, #47, #48, #64, #72, #77, #80, #82) of 24 residents reviewed for advanced directives. The facility census was 80.

Inspectors wroteBased on observation, review of the facility menu, and staff interview, the facility failed to follow the approved menu. This affected 12 (Residents #11, #13, #17, #30, #32, #36, #41, #43, #44, #46 #65 and #76) of 12 residents observed for dining. The facility census was 80.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected five (Residents #6, #14, #25, #33 and #73) of five residents reviewed for environment with the potential to affect all residents residing in the facility. The facility census was 80.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure smoking safety was maintained. This affected 14 individuals observed for smoking and had the potential to affect all residents residing at the facility. The facility census was 80.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a discharge Minimum Data Set (MDS) 3.0 assessment for Resident #70 as required. This affected one resident (Resident #70) of two discharged residents reviewed. The facility census was 80. Findings Include: Medical record review for Resident #70 revealed an admission date of 03/02/18. Diagnoses included seizures, cirrhosis of the liver, chronic obstructive pulmonary disease, anemia, schizoaffective disorder, major depressive disorder, dementia, hypertension, chronic viral Hepatitis C, and hyperlipidemia. Review of the progress notes for Resident #70 revealed the resident was discharged to another facility on 07/13/22 at 12:02 P.M. Review of Resident #70's MDS assessment history revealed the most recent MDS was completed on 06/26/22, which was a quarterly assessment. [...]

Inspectors wroteBased on medical record review, observation, resident interview, and staff interviews, and review of facility policy, the facility failed to ensure skin assessments were completed accurately and failed to ensure physician ordered devices were available for Resident #49. This affected one (Resident #49) of one resident reviewed for foot care. The facility census was 80.

Inspectors wroteBased on medical record review, observation, review of meal tickets, and staff interview, the facility failed to provide supplements with meals as ordered. Additionally, the facility failed to have ordered supplements available. This affected three (Residents #65, #18, and #53) of three residents reviewed for nutritional supplements. The facility census was 80.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure oxygen was administered as ordered. This affected one (Resident #14) of one resident reviewed for oxygen administration. The facility identified seven residents who had physician orders for oxygen. The facility census was 80.

Inspectors wroteBased on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of facility policies, the facility failed to ensure insulin was administered as ordered. This affected one (Resident #47) of four residents reviewed for insulin administration. The facility census was 80.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to maintain accurate medical records. This affected one (Resident #49) of two residents reviewed for maintaining medical records. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure the resident's advance directives were accurate in the medical record. This affected one (#30) of 27 residents reviewed for advance directives. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were provided with timely advanced notices of Medicare skilled services being discontinued. This affected two (#70 and #282) of three residents reviewed for beneficiary notices. The facility identified four residents who were discharged from Medicare skilled services in the last 90 days. The facility census was 84.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to verify placement of an gastrostomy tube prior to administering medications. This affected one (#14) of three residents observed during medication administration. The facility verified Resident #14 was the only resident who received medications via a gastrostomy tube. The census was 84.

Inspectors wroteBased on observation, resident and staff interviews, and medical record review, the facility failed to provide a comfortable mattress. This affected one (#30) of 27 resident's beds observed. The census was 84.