Divine Rehab Toledo: Wound Care Failures Hurt Resident - OH
The wound nurse, LPN #303, told inspectors she called the wound physician after discovering the injury, received new orders, and arranged for the resident to be seen the following day. She confirmed she never documented an assessment of the wound on September 11. Two days passed before anyone had evidence the treatment had actually begun.
The wound physician, identified in the inspection report as WP #400, told inspectors what he believed had happened. Staff were supposed to apply a skin prep solution to Resident #71's right heel and let it dry completely before putting socks back on. Most likely, he said, the prep wasn't drying all the way, and the sock was sticking to the heel, pulling away a layer of skin each time it was removed. He said the resident probably had a deep tissue injury forming on that heel before it ever broke open. Necrosis, he said, can set in within a couple of hours without proper treatment.
The problems ran back further than September 11.
LPN #303 confirmed the facility had no evidence that skin prep was applied to Resident #71's right heel on August 14, August 15, August 20, September 1, September 4, or September 10. There was also no documentation of pressure-offloading boots being in place on the night of August 6, during the day on August 14 and 15, on the night of August 16, or during the day on August 20. Both the skin prep and the offloading boots were ordered treatments, meant to protect a heel already at risk.
Weekly skin checks were supposed to catch exactly this kind of deterioration. LPN #303 told inspectors those checks were typically scheduled around a resident's shower day, set up by unit managers. Resident #71 had no orders in place for weekly skin checks at all. And the facility had no evidence any were completed between August 22 and September 24, a gap of more than a month that covered the entire period the wound was developing.
Four skin checks were documented during the months before the wound opened: August 8, August 15, August 22, and September 24. LPN #303 confirmed that none of them identified or assessed any wound to Resident #71's right heel.
The wound physician said he last saw Resident #71 on September 22, nearly six weeks after the first missed skin prep entry in the record. He said the wound on the heel was debrided at that visit, though the debridement wasn't documented in the wound care notes. He told inspectors he couldn't recall any assessment or monitoring of the right heel, or any treatments beyond the skin prep and offloading boots, and said the resident may have had slough, a buildup of dead tissue, on that heel when he was admitted.
The facility's administrator, interviewed on October 23, confirmed that weekly skin checks should have been completed for Resident #71. The administrator also confirmed that the skin checks that were documented contained no mention of any skin issues to the resident's right heel.
The inspection was conducted on October 27, 2025, following complaints filed under two separate complaint numbers. Inspectors classified the harm level as minimal harm or potential for actual harm, affecting a small number of residents.
Resident #71 had a wound that a physician believes was forming before it ever opened, treated with a protocol that wasn't being followed, monitored through checks that weren't being scheduled, and documented with assessments that recorded nothing wrong. By the time the skin came off in a nurse's aide's hands, the record showed weeks of missed entries where protection should have been.
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 2025-10-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 23, 2026 · Our methodology
DIVINE REHABILITATION AND NURSING AT TOLEDO in TOLEDO, OH was cited for violations during a health inspection on October 27, 2025.
She confirmed she never documented an assessment of the wound on September 11.
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.