Franciscan Care Ctr Sylvania: Fall Not Reported - OH
The nurse who was there when it happened hadn't told the family. Hadn't told hospice. Hadn't even mentioned it to the nurse coming on after her.
The family found out because the resident's daughter came to the facility herself.
According to a nursing progress note dated April 8, 2026, the daughter arrived asking about the specifics of a fall her mother had sustained. Neither she nor hospice had been notified. The fall investigation the facility completed afterward was undated and contained no indication that the resident's representative had ever been contacted.
The resident, identified in inspection records as Resident 27, had lived at the facility since October 2025. She had chronic obstructive pulmonary disease, adult failure to thrive, scoliosis, and a documented history of repeated falls. She needed substantial to maximal help with personal hygiene and was fully dependent on staff for toileting, transfers, and moving in bed. Her cognition was intact. She knew what was happening around her.
The nurse on duty that night, identified in inspection records as Registered Nurse 167, was interviewed by phone on May 19, 2026. She confirmed she was present when Resident 27 fell. She said it was a four-hour shift and very busy. She did not notify the physician. She did not notify the family. And when her shift ended, she did not tell the oncoming nurse about the fall because, she said, there were so many things going on that night.
The Director of Nursing, interviewed the same day, confirmed that notifications should have been made and confirmed they were not completed in a timely manner.
The facility's own fall prevention policy, approved in May 2025, states that the physician and family will be notified after any resident experiences a fall. The policy existed. It was current. It did not get followed.
This was a complaint inspection, triggered by Complaint Number 2982457. Federal inspectors completed their review on May 26, 2026. The violation was cited at a level of minimal harm or potential for actual harm, affecting one of three residents reviewed for falls at a facility with 66 residents.
The harm level designation reflects the regulatory framework inspectors apply, not necessarily what the experience meant to the people involved. Resident 27 was on hospice. Her daughter had to walk into the building and demand to know what had happened to her mother. The fall investigation the facility produced had no date on it and no record of anyone ever picking up the phone.
The nurse's explanation, that the shift was busy and there was too much going on, is the kind of answer that ends an inspection interview. It does not explain why the fall went unrecorded in any communication to the next shift, or why a hospice team coordinating end-of-life care for this woman was left without information that was directly relevant to her condition and safety.
Resident 27's daughter learned about her mother's fall the way no family member should: by showing up and asking.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franciscan Care Ctr Sylvania from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 15, 2026 · Our methodology
FRANCISCAN CARE CTR SYLVANIA in TOLEDO, OH was cited for violations during a health inspection on May 26, 2026.
The nurse who was there when it happened hadn't told the family.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.