Ohio Living Swan Creek
OHIO LIVING SWAN CREEK in TOLEDO, OH — inspection on August 27, 2025.
Found 3 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
Review of the policy titled, Change of Condition: Observing, Recording and Reporting, dated 08/07/24, revealed the facility will record and report any change in condition to the nurse in charge and attending physician so proper treatment will be implemented.
This deficiency represents non-compliance investigated under Complaint Numbers 2566353 and 1358032.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ohio Living Swan Creek
1650 Swan Creek Lane Toledo, OH 43614
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility policy titled, Prevention, Detection, and Treatment of Pressure Ulcers, dated 07/25/25, revealed a pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure in combination with shear and/or friction. A suspected deep tissue injury is purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue and /or shear; the area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared to adjacent tissue.
This deficiency represents non-compliance investigated under Complaint Number 2566353.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ohio Living Swan Creek
1650 Swan Creek Lane Toledo, OH 43614
SUMMARY STATEMENT OF DEFICIENCIES
Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was assessed with severe cognitive impairment, was dependent on staff for the provision of activities of daily living (ADLs), and was incontinent of bowel and bladder.Review of a nursing plan of care dated 07/16/25 revealed a focus area to address Resident #11's bladder incontinence related to requiring assistance with toileting, transfers, and hygiene.
Interventions included to provide staff assistance for toileting task, apply a moisture barrier to the skin, and provide incontinence care after each incontinent episode.
Observation on 09/23/25 at 10:44 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) # 300 discovered Resident #11 in bed. LPN UM #300 removed Resident #11 top sheet and noted Resident #11 to be heavily soiled with urine and a moderate amount of stool. A pervasive urinary odor was also detected.
Interview with LPN UM #300 at the time of the observation confirmed the odor and Resident #11's urinary and bowel incontinence soaking through an adult brief and a Chux (a disposable and absorbent incontinence underpad) pad, and onto the resident's bed linen. LPN UM #300 stated the resident would require a complete bed change and bed bath. LPN UM #300 verified Resident #11 appeared to have been left incontinent for an extensive time.
On 09/23/25 at 10:48 A.M. interview with Certified Nurse Aide (CNA) #200 stated Resident #11 was last checked for incontinence at 7:30 A.M. and at that time Resident #11 refused to get out of bed. CNA #200 stated she did not inform the assigned nurse (LPN #301) of the resident's refusal. CNA #200 went on to verify Resident #11 had not been checked for incontinence or re-approached for care since 7:30 A.M. CNA #200 verified Resident #11 was heavily soiled with urine and stool. On 09/23/25 at 10:54 A.M. interview with LPN #301 revealed the nurse was unaware Resident #11 would not allow CNA #200 to check or change her for incontinence since 7:30 A.M.
Review of the facility incontinence briefs and pad handling, long-term care guideline, reviewed 11/18/24, revealed to help prevent pressure injuries, nursing staff members should minimize folds and wrinkles when applying incontinence product, regularly check for wetness, change product frequently, and inspect the residents skin when changing the product.
Nursing staff should promptly report any changes in the residents skin integrity.
Staff should explain the procedure to the resident and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.
Include the importance of checking the briefs or pad frequently (at least every two hours) and changing it when it is soiled to prevent skin breakdown.
Facility ID: