The abuse occurred at 8:22 P.M. and involved LPN #800 and Resident #169. A second nurse, LPN #801, was also terminated in connection with the incident. The facility's administrator reviewed two minutes of video footage showing the abuse the following day.
Resident #169 told staff the next morning that he did not feel safe in the facility. The director of nursing offered continuous one-on-one supervision with an aide, which the resident accepted. An aide was assigned to directly observe him around the clock.
The resident had already been accepted for transfer to another facility before the abuse occurred. Social Services coordinator #554 notified him that paperwork was being finalized for his move and made transportation arrangements.
On November 17, a psychiatrist evaluated Resident #169. The facility's MDS coordinator updated his care plan to reflect trauma related to physical abuse.
The administrator suspended both nurses on November 16, the day after discovering the incident. LPN #800 and LPN #801 were fired three days later for violating company policy.
The facility conducted extensive interviews following the incident. The administrator spoke with Residents #138 and #145, who were sitting near Resident #169 during the abuse shown in the video. Staff interviews included five employees: two certified nursing assistants and three licensed practical nurses, including the two who were later terminated.
The director of nursing interviewed all residents capable of responding to ensure they felt safe in the facility. These conversations revealed no other safety concerns. Staff also conducted skin assessments on residents who could not be interviewed, finding no negative findings.
All facility staff received mandatory education on November 17 about abuse, neglect, exploitation, and the requirement for timely reporting. Two days later, staff received additional training on resident rights and smoking regulations.
The administrator reported the incident to the state agency on November 16 at 12:25 P.M., assigning it case number SRI #267611. A police report was filed two days later.
The facility held an emergency Quality Assurance and Performance Improvement meeting on November 17 to review the incident and develop an action plan. The monthly QAPI meeting on November 20 included a presentation on the incident and actions taken.
Resident #169 remained under direct observation until his discharge. On November 19 at 1:30 P.M., he left the facility in his electronic wheelchair with all personal belongings. Transportation had been arranged to his new facility.
The director of nursing assessed Resident #169 immediately after learning of the incident on November 16, finding no injuries. However, the psychological impact was evident when the resident expressed feeling unsafe the following day.
The Human Resources Director was notified of the incident on November 16, and the administrator informed the Medical Director the same day. The facility's response included immediate suspension of the involved staff, comprehensive resident safety checks, and facility-wide retraining.
Federal inspectors classified this as causing actual harm to few residents. The incident violated federal requirements for protecting residents from abuse and ensuring their right to be free from mistreatment.
The administrator closed the state incident report on November 21 at 3:32 P.M. The deficiency was investigated under two complaint numbers: 2660931 and 2670000.
Resident #169's transfer to another facility was completed within four days of the incident. The resident had been accepted at the new location before the abuse occurred, but the incident accelerated his departure from Divine Rehabilitation and Nursing.
The facility's security camera system provided clear evidence of the abuse, enabling swift action against the perpetrators. The two-minute video footage showed the incident involving LPN #800 and the resident, with LPN #801 also implicated in the violation.
Staff education following the incident emphasized proper reporting procedures and resident rights. The facility's response included both immediate protective measures for the victim and systemic changes to prevent future incidents.
The terminated nurses were LPN #800, who physically abused the resident, and LPN #801, whose involvement led to termination for policy violations. Both were suspended immediately upon discovery of the incident and fired after the facility's investigation concluded.
Resident #169 required psychiatric evaluation and continuous supervision following the abuse. The trauma was significant enough to warrant updating his care plan and maintaining direct observation until his safe transfer to another facility.
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 2025-12-01 including all violations, facility responses, and corrective action plans.