Divine Rehab Toledo: Wrong Diabetes Drug Given - OH
That was her answer when asked whether she had ordered Trulicity for Resident #39, a man with a diagnosis of Type 1 diabetes. She then told inspectors she did not know him very well, because he had not been in the facility for a long period of time.
Trulicity does not work in patients with Type 1 diabetes. That is not a matter of clinical debate. It is the mechanism of the drug itself.
The facility's own pharmacist, identified in inspection records as Pharmacist #510, told inspectors that Trulicity was not an approved medication for anyone diagnosed with Type 1 diabetes, based on how the drug works. It would not be beneficial, the pharmacist said. It would be an unnecessary treatment.
The physician who spoke with inspectors on December 22 was more direct. Physician #500 said Trulicity was not an appropriate medication for a Type 1 diabetic and was contraindicated. The physician also noted something that any clinician reviewing the medication list should have caught: when a patient is on both long-acting and short-acting insulin together, that combination signals Type 1 diabetes. It is a basic inference, the physician said. Resident #39 was on both.
Nobody had caught it.
The two nurses interviewed the following morning, a licensed practical nurse and a registered nurse identified as LPN #525 and RN #520, both confirmed that Resident #39 had a Type 1 diabetes diagnosis. Both said they did not know Trulicity was not approved for use in Type 1 diabetic patients.
The inspection was conducted in response to a complaint, filed under Complaint Number 2686130. Inspectors cited the facility under F0757, the federal tag covering unnecessary drugs, and assessed the level of harm as minimal harm or potential for actual harm, affecting a small number of residents. The facility is disputing the citation.
What the record shows is a chain of missed signals. A resident arrives with Type 1 diabetes. He is placed on both long-acting and short-acting insulin, the combination that Physician #500 said should itself indicate the diagnosis to anyone reviewing his medications. A nurse practitioner who, by her own account, did not know him well is asked about a drug order for him. Her response is not a clinical assessment. It is a shrug rendered in words.
Trulicity, known generically as dulaglutide, belongs to a class of drugs called GLP-1 receptor agonists. They work by stimulating the body's own insulin production. In Type 1 diabetes, the insulin-producing cells have been destroyed. The drug's mechanism has nothing to act on.
The facility's policy on unnecessary drugs, reviewed by inspectors, states that each resident's entire medication regimen is to be managed and monitored to promote or maintain the resident's highest practicable well-being, free from unnecessary drugs. The policy was undated.
Resident #39 was not in the facility long. The inspection record does not say what happened to him, whether he was discharged, transferred, or what course his care ultimately took. It does not say how long he received the drug before the complaint was filed or before inspectors arrived on December 23. Those details are not in the record.
What is in the record is the nurse practitioner's answer, and the pharmacist's assessment, and the physician's explanation of what any medication review should have shown. They do not point in different directions.
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 2025-12-23 including all violations, facility responses, and corrective action plans.
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: August 20, 2026 · Our methodology
DIVINE REHABILITATION AND NURSING AT TOLEDO in TOLEDO, OH was cited for violations during a health inspection on December 23, 2025.
That was her answer when asked whether she had ordered Trulicity for Resident #39, a man with a diagnosis of Type 1 diabetes.
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.