Inspection·September 2, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based 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. HS #501 stated bugs came from under the towel. Continued interview and observation on 09/02/25 at 9:41 A.M. in the 100-hall shower room revealed the toilet had a towel around the base and when the towel was moved by HS #501's shoe, two bugs crawled out from under it and crawled to the baseboard at the wall. The type of bugs could not be identified. 2. Interview on 09/02/25 at 11:25 A.M. with Housekeeper #512 revealed the bathroom shared by Resident #13, Resident #44, Resident #45, and Resident #46 had several bugs. Continued interview and concurrent observation of the bathroom revealed five to seven fruit flies around the base of the toilet. Housekeeper #512 stated the base of the toilet was not sealed and therefore attracted fruit flies. Additional observation revealed five to seven fruit flies flying around the room. Further observation of the ceiling revealed five to seven fruit flies on the ceiling and the water pipes hanging just below the ceiling. Housekeeper #512 stated the condition of the ceiling, which appeared to have suffered water damage, also attracted fruit flies. Housekeeper #512 confirmed there were fruit flies near the floor, flying around her head, and on the ceiling. Continued observation with Housekeeper #12, upon exiting the bathroom, revealed Resident #46 lying on his bed with his back facing the door. Housekeeper #512 confirmed two house flies were on the seat of Resident #46's pants. An attempt to interview Resident #46 was unsuccessful. Interview on 09/02/25 at 11:31 A.M. with Resident #13 revealed the bugs in the bathroom bothered him. Resident #13 stated he believed they were mosquitoes. Interview on 09/02/25 at approximately 1:35 P.M. with the Administrator revealed the facility was aware of the bathroom ceiling in need of repair. The facility planned to ensure the roof was repaired prior to fixing the bathroom shared by Resident #13, Resident #44, Resident #45, and Resident #46. Interview on 09/02/25 at 3:21 P.M. with HS #501 with concurrent observation of the ceiling in the bathroom shared by Resident #13, Resident #44, Resident #45, and Resident #46 revealed about one quarter of the ceiling appeared to have suffered water damage with the drywall paper layers hanging from the ceiling and discoloration of beige and dark grey throughout the damaged area. Review of the policy Pest Control Policy, dated 06/19/24, revealed the facility recognized the important of pest and vermin control in providing a living environment of adequate health and safety for its residents. This violation represents non-compliance investigated under Complaint Residents Affected - Some (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 2 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 09/02/2025 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)