Franciscan Care Ctr Sylvania
FRANCISCAN CARE CTR SYLVANIA in TOLEDO, OH — inspection on December 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on staff interviews, review of facility investigation, review of a police report, review of the facilities Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to report an allegation of neglect by a nurse to the State Survey Agency, Ohio Department of Health.
This had the potential to affect 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) in which the nurse was responsible for the night of the allegation of neglect.
The facility census was 64.Findings include: Review of the facility provided timeline for 12/12/25 revealed Licensed Practical Nurse (LPN) #200 punched in for work on 12/12/25 at 10:20 P.M. and received report from the off-going LPN, LPN #152, at approximately 11:00 P.M. At approximately 11:12 P.M. on 12/12/25 LPN #152 and Certified Nursing Assistant (CNA) #144 drove LPN #200 to the gas station and he did not return to the facility until 11:27 P.M. on 12/12/25.
Review of the police report revealed on 12/12/25, a resident of the nursing home called emergency 9-1-1 and reported her nurse was intoxicated and smelled like alcohol.
Upon police arrival, LPN #200 had glossy eyes, slurred and abnormal speech.
Police asked Registered Nurse (RN) #158 to contact a supervisor and RN #158 reported she contacted administrative staff.
Due to LPN #200's impairment, policy began an investigation to determine if resident neglect had occurred, was occurring, or was going to occur. On 12/13/25 at 12:45 A.M., LPN #200 was arrested for disorderly conduct: public intoxication; offensive behavior or to cause alarm.
Review of the facilities SRI revealed the facility did not report the allegation of neglect by LPN #200 to the State Survey Agency.Interview on 12/22/25 at 10:46 A.M. with CNA #144 revealed LPN #200 convinced LPN #152 to take him to the gas station.
She stated that she observed a strong smell of alcohol on LPN #200 and called the facilities Administrator and left a voicemail.
She stated that she also called the facility and spoke to RN #158 that was working in the facility at that time.
Interview on 12/22/25 at 12:03 P.M. with the Administrator verified the facility did not file a SRI for this incident.The facility identified LPN #200 was responsible for 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) on 12/12/25.
Review of the facility policy titled Abuse, Neglect, and Exploitation, dated 05/22/25, revealed report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.This deficiency represents non-compliance investigated under Complaint Number 2696625.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Franciscan Care Ctr Sylvania
4111 Holland Sylvania Rd Toledo, OH 43623
SUMMARY STATEMENT OF DEFICIENCIES
Based on staff interviews, review of the police report, review of facility policy, and review of the facility's investigation, the facility failed to complete and thorough investigation of possible resident neglect by a nurse.
This had the potential to affect 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) which the nurse was responsible for the night of the allegation of neglect.
The facility census was 64.Findings include:
Review of the police report revealed on 12/12/25, a resident of the nursing home called emergency 9-1-1 and reported her nurse was intoxicated and smelled like alcohol.
Upon police arrival, Licensed Practical Nurse (LPN) #200 had glossy eyes, slurred and abnormal speech.
Due to LPN #200's impairment, policy began an investigation to determine if resident neglect had occurred, was occurring, or was going to occur. LPN #200 was walking around the facility speaking in a loud voice and using vulgar language in front of residents. On 12/13/25 at 12:45 A.M., LPN #200 was arrested for disorderly conduct: public intoxication; offensive behavior or to cause alarm.
Review of the facility provided timeline for 12/12/25 revealed LPN #200 punched in for work on 12/12/25 at 10:20 P.M. and received report from the off-going LPN, LPN #152, at approximately 11:00 P.M. At approximately 11:12 P.M. on 12/12/25, LPN #152 and Certified Nursing Assistant (CNA) #144 drove LPN #200 to the gas station and he did not return to the facility until 11:27 P.M. on 12/12/25.
The facility interviewed two residents about the allegation of neglect.
The facility identified LPN #200 was responsible for 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) on 12/12/25.Interview on 12/22/25 at 10:46 A.M. with CNA #144 revealed LPN #200 convinced LPN #152 to take him to the gas station.
She stated that she observed a strong smell of alcohol on LPN #200 and called the facilities Administrator and left a voicemail.
Interview on 12/22/25 at 11:35 A.M. with the Director of Nursing (DON) revealed she reviewed the medicals records including the medication administration record (MAR) for all 13 residents assigned to LPN #200 and it was determined he did not administer any medication or provide any care to any residents on 12/12/25.
The DON verified the facility did not assess or interview all 13 residents that were assigned to the care of LPN #200.
Review of the facility policy titled Abuse, Neglect, and Exploitation dated 05/22/25 revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.
Written procedures for investigation include focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and the cause; and providing complete and thorough documentation of the investigation.This deficiency represents non-compliance investigated under Complaint Number 2696625.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.