Continuing Healthcare of Toledo

In the surveyor’s words

From the most serious findings on record at Continuing Healthcare of Toledo, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 29, 2026

  Based on medical record review, staff and resident interviews, review of incidents and accident policy, review of hospital documentation, and review of emergency medical services (EMS) reports, the facility failed to provide assessments, care planning, and monitoring for two residents (#2 and #3) identified with a substance abuse history and failed to investigate incidents when two residents were discovered to have experienced an overdose. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries, and/or negative health outcomes when Resident #2 and Resident #3 were able to obtain and consume drugs they did not have prescriptions for resulting in Resident #2 having three episodes of being found unresponsive within a 32-hour timeframe requiring the administration of… […]

• Actual harm, isolatedF686Aug 15, 2024

  Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure interventions and treatments were implemented for a resident assessed at risk for pressure ulcers to prevent deterioration of an existing stage four pressure ulcer (full-thickness skin and tissue loss) and the development of additional pressure ulcers and failed to ensure pressure ulcer treatments were applied as ordered by the physician. Actual harm occurred to Resident #31 when the facility failed to initiate an alternative pressure relieving cushion or additional pressure reliving intervention to the resident's wheelchair after an existing cushion was damaged and removed and treatments were not administered as ordered. […]

• Actual harm, isolatedF684Apr 27, 2023

  Based on medical record review, review of hospital records, review of a 911 Incident Detail Report, guardian interview, and staff interview, the facility failed to follow the healthcare provider's orders to transport a resident to the hospital when a resident experienced a change in condition. This resulted in Actual Harm when Resident #03's healthcare provider's orders to transport the resident to the hospital when experiencing a low oxygen (O2) saturation level were not immediately followed, delaying transport of the resident to the hospital for several hours, which delayed medical interventions to improve the resident's respiratory status, including mechanical ventilation. This affected one (#03) of three residents reviewed for change in condition. […]

• Actual harm, isolatedF686May 6, 2022

  Based on medical record review, review of hospital records, staff interviews, interview with the wound physician and review of facility policy, the facility failed to timely assess, monitor, and implement treatments for Resident #08's newly developed pressure ulcers (localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure) on the bilateral heels and failed to accurately assess/stage Resident #08's pressure ulcers. This resulted in Actual Harm when Resident #08 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #08 was admitted to the hospital on 04/02/22 due to infection of the right foot and required excisional debridement (surgery) of the right foot on 04/03/22. […]

• No harm, potential for more than minimal, widespreadF804Jul 30, 2025

  Based on observation, test tray review, resident interview, staff interview, review of facility policy, and review of Food and Drug Administration (FDA) guidelines, the facility failed to ensure foods were served at a proper temperature and were palatable. This affected four residents (#32, #51, #54, and #62) of seven residents reviewed for food and had the potential to affect an additional 64 residents who received meals prepared by the kitchen. The facility identified Resident #66 as receiving no food from the kitchen. The facility census was 69. Findings included:Interview on 07/28/25 at 9:28 A.M. with Resident #62 revealed she eats all of her meals in her room and her meals were always cold when delivered and were typically not palatable. Interview on 07/28/25 at 9:30 A.M. […]