Inspection·December 3, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the facility electronic medical record revealed Resident #39 was admitted on [DATE], with diagnoses of: malignant neuroleptic syndrome, anxiety, chronic pain syndrome, urinary incontinence, unspecified lack of coordination, schizophrenia, difficulty in walking, pseudobulbar affect (PBA), delusional disorders, hypertension (HTN), bipolar disorder, psychological and behavioral factors associated with disorders or diseases classified elsewhere, altered mental status, major depressive disorder, other impulse disorder, borderline personality disorder, cognitive communication deficit, unspecified intellectual disabilities, antisocial personality disorder, chromosomal abnormality, schizoaffective disorder, and attention deficit hyperactivity disorder (ADHD) unspecified type. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #39 was cognitively intact. Review of the MDS revealed no abnormal cognitive patterns, moods, or behaviors were assessed. Review of the SRI tracking number 253667 and investigation dated 11/04/24 revealed that on 11/01/24 Certified Nursing Assistant (CNA) #132 was in the employee restroom. While CNA #132 was in the employee restroom, Resident #39 was banging on the door. CNA #132 remained in the employee restroom until Resident #39 stopped banging on the door. When CNA #132 exited the restroom, Resident #39 forcibly approached her. Upon Resident #39 forcibly approaching her, CNA #132 pushed Resident #39, and he fell. After the fall, Resident #39 continued to grab the legs of CNA #139 and was subsequently pulled off by Licensed Practical Nurse (LPN) #138. Review of the SRI revealed Resident #39 was assessed by a nurse and was found to have a skin tear to his left shin and his face was red. There was no treatment required. The investigation was inconclusive as to the cause of the skin tear to his left shin and reddened face. In a written stated from the Director of Nursing (DON), LPN #138 is quoted as stating how Resident #39 became injured was: he must have gotten them from rolling around on the floor, further stating, he must have gotten them when he threw himself on the floor or on the sink in his bedroom, when he threw himself on the floor. Further review of the written statement from the DON revealed that Resident #39 did not complain of any discomfort from the skin tear or reddened face. Resident #39 threatened to spit on CNA #125. (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 10 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 12/03/2024 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)