Divine Rehab: Missed 8 Antibiotic Doses - OH
Resident 34 at Divine Rehabilitation and Nursing at Toledo was hospitalized on August 11 after a choking episode. The 78-bed facility received clear discharge instructions when the patient returned August 13: give Augmentin oral suspension 10.9 milliliters every 12 hours for nine days to treat aspiration pneumonia.
Nobody gave the medication.
The resident's physician order list shows no Augmentin order dated August 13. Instead, the antibiotic didn't appear until August 17 — as a different medication entirely. By then, the patient had missed eight doses over four critical days.
Review of the resident's medication administration record confirmed the gap. From August 13 through August 17, no oral antibiotics were administered despite the hospital's specific discharge orders for immediate treatment.
The Director of Nursing admitted the failure during interviews August 18 and 19. The receiving nurse had not included the hospital discharge orders for Augmentin when processing the resident's return, she confirmed.
When treatment finally began August 17, it was with Amoxicillin instead of the prescribed Augmentin. The new order called for the same 10.9 milliliter dose every 12 hours, but only for five days instead of the original nine-day course.
Resident 34 arrived at Divine Rehabilitation with multiple serious conditions including sepsis, heart failure, difficulty swallowing, gastritis with gastric ulcer, and was receiving palliative care. The patient had impaired cognition and required feeding through a tube, according to nursing assessments completed August 6.
The choking episode that led to hospitalization occurred at 4:18 p.m. on August 11. Hospital staff diagnosed aspiration pneumonia — a dangerous condition where food, liquid, or vomit enters the lungs instead of the stomach. The infection requires immediate antibiotic treatment to prevent potentially fatal complications.
Aspiration pneumonia poses particular risks for residents with swallowing difficulties and feeding tubes. The condition can rapidly worsen without proper medication, especially in patients already compromised by multiple health conditions.
The medication error came to light during a complaint investigation. Federal inspectors reviewed the resident's comprehensive medical records, hospital documentation, and progress notes spanning August 11 through August 19.
Hospital discharge papers clearly specified the antibiotic regimen: Augmentin 400-57 milligrams per 5 milliliters, administered as 10.9 milliliters daily by mouth for nine days. The prescription targeted the specific bacterial infection causing the resident's pneumonia.
Progress notes from August 13 at 3:30 p.m. documented the resident's return with "new order for Augmentin oral suspension 10.9 milliliters oral solution every 12 hours for 9 days for aspiration pneumonia." Despite this clear documentation, the medication never reached the resident.
The facility's medication administration record serves as the official log of all drugs given to residents. The August 2025 record showed a complete absence of oral antibiotics during the critical four-day period following hospital discharge.
When antibiotics finally began August 17, the delayed treatment used Amoxicillin rather than the prescribed Augmentin. While both are antibiotics, they target different bacterial strains and have varying effectiveness against specific infections.
The Director of Nursing's acknowledgment of the error confirmed that receiving staff had failed to properly incorporate hospital discharge orders into the resident's care plan. This breakdown in the transition process left a vulnerable patient without prescribed treatment for aspiration pneumonia.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting one of four residents reviewed for medication administration. The finding represents non-compliance discovered during complaint investigation number 2589259.
The inspection occurred August 20, seven days after the resident's return from the hospital and three days after antibiotics finally began. By then, the patient had already missed more than half of the prescribed nine-day treatment course.
The case illustrates how communication failures between hospitals and nursing homes can leave residents without critical medications. For Resident 34, already battling multiple serious conditions and requiring palliative care, the four-day gap in antibiotic treatment represented a potentially dangerous interruption in pneumonia care at a facility responsible for 78 vulnerable patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Divine Rehabilitation and Nursing At Toledo from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DIVINE REHABILITATION AND NURSING AT TOLEDO in TOLEDO, OH was cited for violations during a health inspection on August 20, 2025.
Resident 34 at Divine Rehabilitation and Nursing at Toledo was hospitalized on August 11 after a choking episode.
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.