Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, resident interview and staff interview the facility failed to ensure a
comfortable mattress was provided following a request. This affected one (#53) of 24 residents reviewed for
reasonable accommodation of needs and requests. The facility census was 73.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses
including cervical disc disorder with myelopathy, chronic venous hypertension with ulcer of bilateral lower
extremity, chronic obstructive pulmonary disorder, type 2 diabetes mellitus, spinal stenosis, benign prostatic
hyperplasia, neuromuscular dysfunction of bladder, mood disorder, chronic kidney disease stage 4,
hypertension, coronary artery disease, congestive heart failure, and muscle weakness. According to the
most current Minimum Data Set (MDS) assessment dated [DATE], Resident #53 had intact cognition, had
range of motion impairment to upper and lower bilateral extremities, was dependent on staff for the
completion of activities of daily living including bed mobility, was incontinent of bowel and bladder, and was
at risk for pressure ulcer development with no skin breakdown.
On 02/14/25 a skin risk assessment completed for Resident #53 revealed score of 14, indicating moderate
risk for developing skin breakdown.
According to a physician order dated 12/27/24 a low air loss mattress was to be placed in use, instructions
included to monitor function and settings every shift.
Observation on 04/14/25 at 9:09 A.M. noted Resident #53 in bed with the air mattress in place. Resident
#53 stated the air mattress was partially inflated and his buttock was resting against the bed frame. The
resident stated he requested a new mattress in December and one had not been provided.
On 04/15/25 at 9:18 A.M. observation with Licensed Practical Nurse (LPN) #527 assessed Resident #53
while in the bed with the air mattress in place. LPN #527 verified Resident #53 buttock in contact with the
bed frame. Additional observation noted Resident #53 had no current skin breakdown, however, scaring
was identified from previously healed skin breakdown.
On 04/16/25 at 7:40 A.M. interview with LPN #532 revealed nursing staff are to check Resident #53's air
mattress setting each shift. LPN #532 was aware Resident #53 had reported concerns with the comfort of
the mattress. LPN #532 stated the air mattress settings were determined appropriate and no attempts to
obtained a replacement air mattress had occurred.
This deficiency represents non-compliance investigated under Complaint Number OH00163310.
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 14
Event ID:
366060
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, and staff interview, the facility failed to ensure interventions to address
edema were initiated. This affected one (#01) of two residents reviewed for edema prevention and
monitoring. The facility census was 73.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #01 admitted to the facility on [DATE] with diagnoses
including anoxic brain damage, anxiety disorder, contracture to bilateral hands, elbows and shoulders,
localized edema, and chronic pain. According to the most current Minimum Data Set (MDS) assessment
dated [DATE], Resident #01 had severely impaired cognition, no refusals of care, bilateral upper and lower
extremity range of motion impairment, was dependent on staff for all activities of daily living, was
incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown.
Observation on 04/14/25 at 8:55 A.M. noted Resident #01 seated in a specialized wheelchair with bilateral
arms resting dependent at her sides. Resident #01's left hand was observed with edema and a closed fist.
Observations on 04/15/25 at 5:46 A.M., 11:43 A.M., 12:42 P.M., 04/16/25 at 5:37 A.M., 11:43 A.M., and
12:42 P.M. noted Resident #01 in bed with bilateral arms resting dependently at each side and hands with
closed fists.
On 04/17/25 at 8:35 A.M. observation with Licensed Practical Nurse (LPN) #523 assessed Resident #01
with one plus pitting edema to the left hand and middle forearm. LPN #523 verified no interventions were
contained in the medical record to address Resident #01 history of edema.
On 04/17/25 at 8:40 A.M. interview with LPN #529 during review of Resident #01's medical record verified
Resident #01 with dependent edema to left hand and forearm. LPN #529 verified Resident #01 did not have
interventions in place to address the edema.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 2 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, and staff interview, the facility failed to ensure interventions were
implemented to prevent deterioration of contractures. This affected one (#01) of two residents reviewed for
range of motion and positioning. The facility census was 73.
Findings include:
Review of the medical record revealed Resident #01 admitted to the facility on [DATE] with diagnoses
including anoxic brain damage, anxiety disorder, contracture to bilateral hands, elbows and shoulders,
localized edema, and chronic pain. According to the most current Minimum Data Set (MDS) assessment
dated [DATE], Resident #01 had severely impaired cognition, no refusals of care, bilateral upper and lower
extremity range of motion impairment, was dependent on staff for all activities of daily living, was
incontinent of bowel and bladder, and at risk for pressure ulcer development with no skin breakdown.
On 08/27/21 a physician order was written to place a washcloth in each of Resident #01's hands to keep
fingers from clenching into palms of hands every shift due to bilateral hand contractors.
On 08/09/23 a nursing plan of care was implemented to address Resident #01's impaired musculoskeletal
status related to contractures with interventions to include for Resident #01 to be free of complications
related to altered musculoskeletal status through the next review, administer treatments as ordered,
observe for and report to nurse any pain or skin integrity issues related to use of the washcloth in hands,
cleanse hands and dry completely prior to application of washcloths in hands, and to provide range of
motion (ROM) as indicated prior to use of washcloth in hands to keep fingers from clenching into palms of
hands.
In addition, on 02/25/24 a nursing plan of care was implemented to address Resident #01's inability to
participate in a restorative programs related to the distress it caused her. Resident #01 does not tolerate
passive range of motion (PROM) to her bilateral hands as they are severely contracted and when doing
PROM Resident #01 has facial grimacing and and starts to cry and scream, and pulling hands away.
Interventions included to clean bilateral hands with A.M. and P.M. care, as tolerated. If distress is noted
(crying or facial expressions) stop and reapproach as needed. Monitor for signs and symptoms of skin
breakdown to bilateral hands.
Observation on 04/14/25 at 8:55 A.M. noted Resident #01 seated in a specialized wheelchair with bilateral
arms resting dependently at her sides. No washcloths were in place to either hand and both hands fists
were closed.
Observations on 04/15/25 at 5:46 A.M., 11:43 A.M., 12:42 P.M., 04/16/25 at 5:37 A.M. revealed no
washcloths were in place and Resident #01's hands were closed fisted.
On 04/16/25 at 10:16 A.M. interview with Certified Nurse Aide (CNA) #569 revealed she assumed care at
6:00 A.M. for Resident #01 and verified no washcloths had been in place to either hand since the beginning
of the shift.
On 04/16/25 at 11:45 A.M. interview with Licensed Practical Nurse (LPN) #508 verified washcloth
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 3 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0688
rolls had not been in place as ordered by the physician for Resident #01.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 4 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and facility policy, the facility failed to ensure fall
interventions were implemented as indicated. This affected one (#24) of three residents reviewed for fall
management. The facility census was 73.
Findings include:
Resident #24's medical record review revealed the resident admitted to the facility on [DATE] with
diagnoses including type 2 diabetes mellitus, cerebral infarction, [NAME] lymphoma, hypertension, seizure
disorder, abnormal posture, chronic kidney disease stage 3, coronary artery disease, anemia, traumatic
subdural hemorrhage without loss of consciousness, and cardiac arrhythmia.
According to the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #24 was
assessed with severe cognitive impairment, no recorded refusal of care, utilized a wheelchair for mobility,
required substantial to maximal assistance with activities of daily living, incontinent of bowel and bladder.
Review of the fall assessment dated [DATE] at 8:06 P.M. noted Resident #24 was found on the floor on the
side of the bed. On 03/02/25 at 10:33 P.M. a follow-up fall assessment was completed and indicated new
interventions to prevent further injury from falls was implemented.
According to progress note dated 03/02/25 at 3:07 A.M., Resident #24 fell out of bed trying to ambulate to
the restroom on 03/01/25 and was found sitting on the floor on the side of bed. Resident #24 had no
complaints of pain and was assisted with transfer back into bed. Nursing interventions in place included
keeping bed in low position, and the call light within reach for assistance.
On 03/03/25 at 10:55 A.M. the Interdisciplinary Team progress note documented Resident #24 was found
sitting on the floor next to her bed after attempting to ambulate to the bathroom. No injuries were noted and
both the physician and family were notified. A new intervention to apply hipsters was implemented.
On 03/26/25 a nursing plan of care was revised to address Resident #24's risk for falls/injury related to
decreased strength and endurance, generalized weakness, poor balance, and seizures. Interventions
included hipsters as tolerated, toileting and repositioning every two hours, taking the resident to the
common area when increased anxiety was identified, and encourage the resident to use the call light.
Observation on 04/17/25 at 6:37 A.M. noted Resident #24 seated in a wheelchair with her eyes closed. No
hipsters were in place. Interview with Licensed Practical Nurse (LPN) #529 at the time of observation
verified Resident #24 did not have hipsters applied as indicated.
According to facility Accidents and Supervision policy revised 12/27/2023. Each resident will be assessed
for accident risk and will receive care and services in accordance with their individualized care plan. This
included implementing interventions to reduce hazards or risk. Using specific interventions to try to reduce
a residents risk from hazards in the environment. Interventions are based on the results of the evaluation
and analysis of information about the hazards or risks and are
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 5 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
consistent with relevant standards, including evidence-based practice. Monitoring is the process of
evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions
as needed to make them more effective in addressing hazards and risks.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 6 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, resident interview, staff interview, and facility policy the facility failed to
ensure timely care and treatment was provided to address incontinence. This affected two (#40 and #63) of
five residents reviewed for bowel and bladder incontinence services. The facility census was 73.
Findings include:
1. Review of the medical record revealed Resident #40 admitted to the facility on [DATE] with the diagnoses
including metabolic encephalopathy, severe protein-calorie malnutrition, depressed mood, stage 2 pressure
ulcer to sacral region and left buttock. dysphagia, and anemia. According to the most current Minimum Data
Set (MDS) assessment dated [DATE], Resident #40 was assessed with moderately impaired cognition,
range of motion impairments to the bilateral upper and lower extremities, dependency on staff for the
completion of activities of daily living including bed mobility and incontience care as Resident #40 was
always incontinent of bowel and bladder. Resident #40 was at risk for pressure ulcer development and
admitted with two stage two pressure ulcers.
On 03/24/25 the nursing plan of care was revised to address Resident #40's episodes of bladder and bowel
incontinence. Interventions included to assist Resident #40 with toileting needs, check at regular intervals
and change as needed, provide disposable incontinence products, provide peri-care after each
incontinence episode and apply house barrier cream after incontinence care. No specific interval of
incontinence monitoring was contained in the medical record.
Review of the task documentation between 03/19/25 and 04/15/25 recorded Resident #40 to be incontinent
daily. However, no frequency of check and change was identified.
Observation on 04/15/25 at 5:52 A.M. noted Resident #40 in bed positioned to the right. Continued
observation between 5:52 A.M. and 9:14 A.M. noted Resident #40 remained in bed on the right side without
repositioning or incontinence checks.
On 04/15/25 at 6:04 A.M. interview with Certified Nurse Aide (CNA) #537 revealed she assumed the care
for Resident #40 on 04/14/25 at 10:00 P.M. and continued care until 04/15/25 at 6:00 A.M. CNA #537 stated
Resident #40 required every two-hour incontinence checks and repositioning and was last provided
incontinence care and repositioning at 4:30 A.M.
Interview on 04/15/25 at 9:14 A.M. with CNA #554 verified she assumed the care for Resident #40 at 6:00
A.M. and had not checked Resident #40 for incontinence or provided repositioning since assuming care at
6:00 A.M. CNA #554 stated she was unaware when Resident #40 was last checked for incontinence or
repositioning.
Observation on 04/15/25 at 9:31 A.M. with CNA #554 noted Resident #40 was heavily soiled with urine
through an adult brief onto linen covering (chux). Two wound dressings were observed to Resident #40 left
upper thigh and left sacrum.
2. Review of the medical record for Resident #63 revealed the resident was admitted to the facility on
[DATE] with diagnoses including, dorsopathy, chronic obstructive pulmonary disease, obstructive
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 7 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
sleep apnea, abnormal posture, anxiety disorder, depression, hypertension, and fibromyalgia. According to
the most current MDS assessment dated [DATE], Resident #63 was cognitively intact, had the ability to
make needs known, and had no history of refusing care. Resident #63 had limited range of motion to
bilateral lower extremities, required substantial to maximal assistance with activities of daily living, was
dependent on staff for bed mobility, was always incontinent of bowel and bladder, and was at risk for
pressure ulcer development with no current skin breakdown.
On 12/04/24 a nursing plan of care was revised to address Resident #63 risk for episodes of bowel and
bladder incontinence. Interventions included to assist the resident with toileting needs, provide disposable
incontinence products, provide peri-care after each incontinence episode and apply in-house barrier cream
after each incontinence care.
Review of skin assessment dated [DATE] identified a new abnormal skin area with redness and excoriation
to the groin.
Observation on 04/14/25 at 9:56 A.M. noted Resident #63 in bed. Resident #63 stated she requires every
two hour incontinence checks and repositioning and the staff is not providing the care. As a result of not
receiving care, Resident #63 stated she developed excoriation and a rash.
On 04/15/25 at 5:57 A.M. Resident #63 was observed positioned on her back with eyes closed. Continued
observation on 04/15/25 between 5:57 A.M. and 8:04 A.M. noted Resident #63 in bed positioned on her
back with no repositioning or incontinence checks or care attempted.
On 04/15/25 at 6:07 A.M. an interview with Certified Nurse Aide (CNA) 537 revealed she had provided
Resident #63 with incontinence care and repositioning at 4:25 A.M. CNA #537 stated Resident #63 is
unaware when she is incontinent and needed to be checked and repositioned every two hours.
On 04/15/25 at 8:04 A.M. an interview with Resident #63 revealed she had been incontinent of urine and no
checks or repositioning had occurred since night shift.
On 04/15/25 at 8:41 A.M. an interview with CNA #554 revealed she was looking for incontinent wipes due
to Resident #63 being excoriated. CNA #554 stated she did not want to use rough washcloths. At 09:02
A.M. CNA #554 proceeded to check Resident #63 for incontinence. Resident #63 was observed with
excoriated perineum including the pan and groin. Resident #63 was incontinent of a large amount of urine
and small formed bowel movement. CNA #554 right upper thigh was also excoriated. Two adult
incontinence briefs were discovered under the resident and both were soiled.
On 04/15/25 at 9:14 A.M. following resident care, interview with CNA #554 verified the check and change at
9:02 A.M. was the first contact CNA #554 had with Resident #63 since assuming care at 6:00 A.M. CNA
#554 was unaware when Resident #63 was last checked, changed or repositioned. CNA #554 verified the
resident is to be checked and changed every two hours with repositioning.
According to the facility policy titled Incontinence, revised 10/26/2023, stated based on the resident's
comprehensive assessment, all residents that are incontinent will receive appropriate treatment and
services. Residents that are incontinent of bladder and bowel will receive appropriate treatment to prevent
infections and to restore continence to the extent possible.
This deficiency represents non-compliance investigated under Complaint Number OH00163310.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 8 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interview, and review of the facility policy, the facility failed to ensure
oxygen was running at the prescribed rate. This affected one resident (#29) reviewed for oxygen therapy.
The facility identified 15 residents required the use of oxygen therapy. The facility census was 73.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #29 revealed an admission date of 12/09/22 with admitting
diagnoses of heart failure and end stage renal disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 revealed he
was cognitively intact and required the use of oxygen.
Review of the care plan revised 02/25 for Resident #29 revealed he was care planned for impaired
cardiovascular stated related to heart failure with an intervention for oxygen therapy as ordered.
Review of the current physician orders for 04/25 revealed Resident #29 was ordered oxygen at two liters
per minute continuously via nasal cannula.
Observation on 04/14/25 at 11:51 A.M. of Resident #29 revealed he was sitting in his wheelchair with a
portable oxygen tank running at three liters per minute.
Interview on 04/14/25 at 11:54 A.M. with Licensed Practical Nurse (LPN) #526 verified oxygen for Resident
#29 was running on the portable oxygen tank at three liters per minute and verified the order from the
physician was for the oxygen to be running at two liters per minute.
Review of the facility policy titled Oxygen Administration, revised 10/23 revealed oxygen is administered
under orders of physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 9 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and facility policy, the facility failed to ensure alternative
and non-pharmacologic interventions were implemented to address pain in accordance with physician
orders. This affected one (#177) of two residents reviewed for pain control interventions. The facility census
was 73.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #177 admitted to the facility on [DATE] with diagnoses
including cauda equina syndrome, spinal stenosis lumbar region, abnormal posture, chronic venous
hypertension, chronic pain, chronic fatigue, allergy status to unspecified drugs, medications and biological
substances, and lumbago with sciatica. According to the most current Minimum Data Set (MDS)
assessment dated [DATE], Resident #177 was cognitively intact, was able to make needs known, had
limited bilateral lower extremity range of motion, required substantial to maximal assistance with activities
of daily living, received scheduled and as needed (PRN) pain medications and had non-medication
interventions in place for pain.
Review of hospital community referral physician orders dated 04/01/25 noted non-pharmacological wound
care instructions to include the application of an ice pack to the surgical incision to help with pain. The ice
pack was to be applied 15 to 20 minutes at a time, five to six times daily.
On 04/02/25 a nursing plan of care was implemented to address Resident #177 pain related to back
surgery, surgical incision, and verbal complaints of pain. Interventions included the following: administer
medications as ordered and observe for effectiveness. Offer non-pharmacological interventions to relieve
pain and observe for effectiveness. Further review of the plan of care lacked documentation describing
specific non-pharmacological interventions.
Review of physician orders lacked documentation indicating the ice packs and lacked where and when the
ice packs were to be applied.
Review of the administration records for Resident #177 lacked documentation regarding the ice packs.
Observation on 04/14/25 at 10:00 A.M. noted Resident #177 seated in a wheelchair at the bedside.
Interview with Resident #177 stated she was experiencing a pain level of 8 (level zero, no pain and level 10
indicating severe pain) in back, hips, legs. Resident #177 described the pain as a burning sensation.
Resident #177 stated she had multiple medication allergies and would like non-pharmacological
interventions between scheduled pain medication administrations. The resident stated she had not had any
non-pharmacological interventions provided the past two nights.
Additional interview on 04/15/25 at 5:54 A.M. with Resident #177 stated she spoke with her surgeon and
indicated she was to receive ice applications five to seven times daily for 20 minutes and increased the
dose of gabapentin. Resident #177 reported a pain level of 5 at the time of the interview. Resident #177
verified no alternative methods of pain relief were being provided, adding only pain medications have been
provided. On 04/15/25 at 2:34 PM Resident #177 was observed in bed requesting an ice pack.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 10 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0697
Level of Harm - Minimal harm
or potential for actual harm
Observation on 04/16/25 at 12:50 P.M. of Resident #177 revealed the resident was in bed and reported a
pain level of 5 to low back, bilateral hips and lower extremities. Interview with Resident #177 at the time of
the observation revealed the resident had not been receiving ice packs between scheduled pain medication
to control pain as requested. Continued observation noted disposable ice pack warm to touch at Resident
#177 bedside.
Residents Affected - Few
On 04/16/25 at 12:55 P.M. interview with Certified Nurse Aide (CNA) #551 verified Resident #177 was
given an ice pack at 7:00 A.M. CNA #551 confirmed Resident #177 was required to request an ice pack.
On 04/16/25 at 1:00 P.M. interview with the Director of Nursing (DON) during review of the medical record
for Resident #177 verified the record lacked evidence of ice packs being provided as ordered. In addition,
the DON verified no non-pharmacologic intervention related to the application of an ice pack was listed on
pain care plan.
According to the Pain Management policy revised 10/26/2023. The facility will ensure that pain
management is provided to residents who require such services, consistent with professional standards of
practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The
interventions for pain management will be incorporated into the components of the comprehensive care
plan, addressing conditions or situations that may be associated with pain or may be included as a specific
pain management need or goal. If re-assessment findings indicate pain is not adequately controlled, revise
the pain management regimen and plan of care as indicated.
This deficiency represents non-compliance investigated under Complaint Number OH00164044.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 11 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based
observation, staff interview and review of facility policy, the facility failed to ensure adequate infections
control practices were carried out. This had the potential to affect the 38 residents (#55, #37, #4, #33, #50,
#5, #29, #47, #17, #11, #35, #28, #26, #9, #44, #42, #41, #18, #51, #43, #67, #7, #15, #25, #30, #6, #277,
#52, #24, #12, #22, #8, #36, #54, #13, #27, #1, and #49) who resided on the 100 and 200 hallways. The
facility census was 73.
Residents Affected - Some
Findings include:
1. Observation on 04/14/25 at 9:18 A.M. of the 200 hallway found four rooms identified as being on droplet
isolation. Personal Protective Equipment (PPE) including gowns, gloves, respirators (N-95s), and a face
shields were available for each room on the over the door organizer. Signs with directions for donning
personal protective equipment (PPE) were posted on the doors.
Observation on 04/14/25 at 9:21 A.M. found Certified Nursing Assistant (CNA) #562 donned a gown, N-95,
gloves and face shield and entered room [ROOM NUMBER].
Observation on 04/14/25 at 9:24 A.M. found CNA #562 had removed gown, gloves inside the room and
placed the face shield back in the over the door organizer. CNA #562 did not disinfect the face shield after
use.
Interview on 04/14/25 at 9:25 A.M. with CNA #562 verified the face shields were reused and he had placed
the used face shield back in the over door organizer after exiting the room.
Observation on 04/14/25 at 9:26 A.M. of CNA #562 found CNA #562 donned a gown, gloves, a N-95, and
the face shield from the over the door organizer from room [ROOM NUMBER]. CNA #562 did not disinfect
the face shield prior to applying the face shield and entering room [ROOM NUMBER].
Observation on 04/14/25 at 9:29 A.M. of CNA #562 found CNA #562 exited room [ROOM NUMBER] having
doffed gown and gloves. CNA #562 removed his face shield and placed it back into the over the door
organizer without disinfecting the face shield. Coinciding interview with CNA #562 verified there were
bleach wipes available at the nurses station for disinfecting surfaces and had not been used on the face
shields.
Review of the undated posted signage with the steps for removing personal protective equipment (PPE)
revealed in step two of the process it stated the outside of the goggles or face shield were contaminated. If
the item was reusable, it was to be placed in designated receptacle for reprocessing, or otherwise discard
in the waste container.
Review of the facility policy titled, Infection Prevention and Control Program, revised 10/24/22 revealed all
reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in
accordance with out current procedure governing the cleaning and sterilization of soiled or contaminated
equipment. Single use devices must be discarded after use and are never used for more than one resident.
2. Observation on 04/15/25 at 7:48 A.M. revealed Certified Nurse Assistant (CNA) #562 delivered a
breakfast tray into room [ROOM NUMBER] without performing hand hygiene. CNA #562 then exited room
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 12 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
without performing hand hygiene and proceeded to room [ROOM NUMBER] which was a Covid isolation
room. CNA #562 then proceeded to don all required PPE including gown, N-95, face shield, and gloves and
entered the Covid isolation room without performing hand hygiene. CNA #562 then delivered a morning
breakfast tray into room. Upon exiting the room and removing PPE CNA #562 did not perform hand hygiene
and walked down the hall towards nursing station.
Residents Affected - Some
Interview on 04/15/25 at 7:55 A.M. with CNA #562 confirmed no hand hygiene was performed before or
after entering neither room [ROOM NUMBER] or 207.
Review of the undated posted signage with the steps for removing PPE revealed that step four is to wash
hands or use an alcohol-based hand sanitizer immediately after removing all PPE.
Review of policy titled, Hand Hygiene with a revised date of 12/13/2023 revealed that all staff will perform
hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This
applies to all staff working in all locations within the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 13 of 14
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
366060
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Sylvania
7120 Port Sylvania Drive
Toledo, OH 43617
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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, and review of the facility policy, the facility failed to keep the privacy curtain
clean in the residents room. This affected one resident (#5) of 24 reviewed for environment. The facility
census was 73.
Findings include:
Review of the medical record for Resident #5 revealed an admission date of 04/12/21 and an admission
diagnosis of dementia.
Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed he was cognitively
impaired and was dependent for all care.
Review of the care plan revised 02/25 for Resident #5 revealed he was care planned for behaviors related
to dementia of taking his brief off in bed.
Observation on 04/15/25 at 1:28 P.M. revealed Resident #5's privacy curtain had several brown stains that
were unidentifiable along the bottom of the privacy curtain approximately one third up the privacy curtain
and approximately two feet in length.
Interview on 04/15/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #569 verified the unidentified
brown stains on the privacy curtain of Resident #5.
Review of the facility policy titled, Routine Cleaning and Disinfection, revised 02/22 revealed privacy
curtains in resident rooms will be changed with visibly dirty by laundering or cleaning with registered
disinfectant per managers instructions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366060
If continuation sheet
Page 14 of 14
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Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
FAQ · About this visit
Common questions about this visit
What happened during the April 17, 2025 survey of ARBORS AT SYLVANIA?
This was a inspection survey of ARBORS AT SYLVANIA on April 17, 2025. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ARBORS AT SYLVANIA on April 17, 2025?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.