Inspection·October 29, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Observation on 10/28/24 at 7:05 A.M., upon entering the facility revealed the ceiling light with missing a cover, brown stained and bowing ceiling tiles, carpeting pulled away from the wall, dark brown streaks and various odd, shaped areas of black discoloration on the tan colored bench and the two blue and white chairs, brown colored carpeting with dark colored staining and worn, thinning paths in front of the facility locked entry door, and spider webs and dust hanging from the ceiling where the wall and ceiling join. Additional observations during the facility tour on 10/28/24 from 9:00 A.M. until 11:30 A.M. revealed: • The ceiling vent in the hallway outside rooms 37, 38 and 39 covered with a thick layer of dust; • A thick layer of dust on the wall behind the hallway handrails; • A thick layer of dust on the fire alarm boxes; • Missing ceiling tiles exposing wires and the metal drop ceiling framing outside the lower-level dining room; • (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365030 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Care Center of Toledo 3121 Glanzman Rd Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)