Concord Care Center of Toledo

In the surveyor’s words

From the most serious findings on record at Concord Care Center of Toledo, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jan 17, 2023

  Based on closed medical record review, staff interviews, physician interview, review of the facility investigation, review of an emergency medical services (EMS) report, review of the United States National Library of Medicine, National Institute of Health website, and review of facility policy regarding a change in a resident's condition, the facility failed to notify the physician of a significant change in condition for one resident (Resident #140). This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when Resident #140 experienced a low pulse oximetry (pulse-ox) level (a measure of the oxygen saturation of the blood) without physician notification of the change in status and that EMS assessed the resident at the facility and declined transport to the… […]

• Immediate jeopardy, isolatedF678Jan 17, 2023

  Based on closed medical record review, staff interviews, physician interview, review of the facility investigation, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, and review of the American Heart Association Journal, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) or contact emergency medical services (EMS) for one resident (Resident #140) found unresponsive, without a pulse, respirations, or pulse-oximetry (pulse ox) reading, and who was identified as a Full Code status. This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when Resident #140 did not receive CPR after she was discovered with no pulse, respirations, or pulse-ox and EMS was not contacted for assistance. […]

• Immediate jeopardy, isolatedF684Jan 17, 2023

  Based on closed medical record review, staff interviews, physician interview, review of the facility investigation, review of the emergency medical services (EMS) report, review of the United States National Library of Medicine, National Institute of Health website, and review of facility policy regarding change in a resident's condition, the facility failed to provide assessments and monitoring of a resident with a significant change in condition, send the resident to the hospital when needed, and failed to notify the physician of the change of condition and lack of transport to the hospital for one resident (#140). […]

• Actual harm, isolatedF689Jul 31, 2025

  THIS 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. […]

• Actual harm, isolatedF689Sep 21, 2023

  Based 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. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. […]