Divine Rehabilitation And Nursing At Toledo

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, review of hospital documentation, and staff interview, the facility failed to administer medications as ordered by the physician. This affected one (#34) of four residents reviewed for medication administration. The current census is 78.Findings include:Record review for Resident #34 revealed the resident was admitted to the facility on [DATE REDACTED]. Diagnoses for Resident #34 include sepsis, heart failure, dysphagia, sepsis due to enterococcus, gastritis with a gastric ulcer, and encounter for palliative care.

Review of Resident #34's comprehensive Minimum Data Set, (MDS) date 08/06/25 revealed the resident had impaired cognition and was receiving parental nutrition via a feeding tube. Review of Resident #34's progress notes dated from 08/11/2025 to 08/19/2025 revealed by the note dated 08/11/25 at 4:18 P.M.

Resident #34 was having a choking episode and was transferred to the hospital for treatment. Review of Resident #34's hospital paperwork for discharge back to the facility on [DATE REDACTED] revealed the resident was ordered to start taking Augmentin (antibiotic) 400-57 milligrams/ 5 milliliters (mg/ml) give 10.9 ml daily orally for 9 days for aspiration pneumonia. Review of Resident #34's progress notes dated 08/13/25 at 3:30 P.M.

the resident returned to the facility with a new order for Augmentin oral suspension 10.9 milliliters (m1) oral solution every 12 hours for 9 days for aspiration pneumonia. Further review of Resident #34's physician ordered medication list dated August 2025 revealed the resident was not ordered to start the antibiotic until 08/17/25. No order for the Augmentin antibiotic dated 08/13/25 was noted in the orders. The order dated 08/17/25, revealed Resident #34 was ordered to receive Amoxicillin (antibiotic) 10.9 mls oral solution every 12 hours for 5 days. Review of Resident #34's Medication Administration Record (MAR) dated August 2025 revealed the resident did not receive any oral antibiotic from 08/13/25 to 08/17/25. Interviews on 08/18/25 at 3:30 P.M. and on 08/19/25 at 2:15 P.M., with the Director of Nursing, (DON) verified when Resident #34 returned to the facility the receiving nurse did not include the hospital discharge orders for the Augmentin oral antibiotics. The DON verified the Augmentin oral antibiotic started to be given as physician order on 08/17/25 for 5 days and the resident had missed 8 doses of the medication from 08/13/25 to 08/17/25. This deficiency represents non-compliance discovered during the investigation for Complaint Number 2589259

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Divine Rehabilitation and Nursing at Toledo

1011 North Byrne Road Toledo, OH 43607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

aide from activities, Recreation Assistant (RA) #125 was passing out food to residents and RA #125 heard

the resident coughing and yelling for help. RA #125 got the nurse, who assessed Resident #34 and found her coughing and drooling, with pieces of watermelon on her shirt. RN #216 stated she took the resident's vitals and called for emergency services to transport the resident to the hospital for treatment. During an

interview on 08/18/25 at 11:17 A.M, RA #250 stated she was not the aide who passed the watermelon to Resident #34; however, she was working the day of the incident. The recreation aides are not educated on

the resident's dietary restrictions. During an interview on 08/18/25 at 11:25 A.M., Director of Recreation (DOR) #123 stated on 08/11/25, RA #125 was newly hired to the facility and on 08/11/25, RA #125 was passing watermelon during activities. DOR #123 uses the dietary restriction sheet provided to know the resident's diet orders and restrictions. DOR #123 stated she instructed RA #125 to pass snacks on the 100 and 200 halls. DOR #123 stated RA #125's mother was working on the 100 hall on 08/11/25. DOR #123 stated she assumed RA #125's mother would instruct her on how to pass snacks to the residents on the hall she was working. DOR #123 stated she instructed RA #125 to pass snacks and then go back to the kitchen after she was done on 100 and 200 halls. DOR #123 stated RA #125 did not return to the kitchen

after she was done passing the watermelon to the 100 and 200 halls and had left over watermelon. RA #125 continued to pass the watermelon to the residents in the 400-hall, including Resident #34. DOR #123 stated RA #125 received education after the incident. During an interview on 08/18/25 at 11:54 A.M. and on 08/19/25 at 10:00 A.M., the Administrator verified Resident #34 was served watermelon by RA #125 even though her diet order was NPO. All activity staff have been educated to review all residents dietary restrictions prior to providing any food the residents. Attempts to contact RA #125 on 08/18/25 and 08/19/25 were unsuccessful. Review of RA #125's personnel file revealed she was hired on 08/10/25. There was no evidence RA #125 had been educated on resident dietary restrictions to ensure safety when eating.

Review of the policy titled, Therapeutic Diet Order , undated, revealed the facility will provide all resident with food the appropriate consistency in accordance with physician orders and plans of care. This deficiency represents non-compliance investigated under Complaint Number 2589259.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Divine Rehabilitation and Nursing at Toledo

1011 North Byrne Road Toledo, OH 43607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observed, review of facility's temperature log, review of facility policy, and staff interview, the facility failed to ensure all food was stored at appropriate temperatures. This has the potential to affect all residents with the exception of Resident #34 and Resident #19 (two residents identified as not receiving any food from the kitchen). The current census is 78. Findings include: Review of the facility's temperature logs dated August 2025 for the refrigerator revealed the lowest temperature for the refrigerator was recorded as 50 degrees with the highest temperature recorded was 65 degrees. Observation on 08/18/25 at 7:16 A.M. during a kitchen tour revealed the walk-in refrigerator temperature gauge read 50 degrees.

During the observation there was no internal thermometer observed in the walk-in refrigerator. The walk-in freezer was in the back of the walk-in refrigerator and the outside temperature gauge for the freezer section was noted as -10 degrees. Ice was observed accumulating in the freezer around the fan. Interview on 08/18/25 at 7:16 A.M. with [NAME] #184 verified the walk-in refrigerator was not working properly and the temperature was at 50 degrees. Per [NAME] #184 the staff have been opening the freezer door to cool down the refrigerator portion of the refrigerator section. Interview on 08/19/25 at 2:15 P.M. with Director of Maintenance (DOM) #217 verified since the beginning of August 2025 the refrigerator in the front of the walk-in section was not cooling and keeping the food stored at a temperature below 42 degrees. DOM #217 stated the maintenance staff have put in requests for repairs and are waiting for funding and bids to be approved to repair the refrigerator. DOM #217 stated the kitchen staff have been opening the freezer doors to keep the refrigerator portion cool. DOM #217 verified the temperature of the refrigerator does not stay below 42 degrees during the evening and at times during the day when no staff are available to monitor the temperatures and keep the freezer door open. DOM #217 verified there was ice accumulation in the freezer due to condensation from times when the door is open to the refrigerator. Interview on 08/19/25 at 3:33 P.M. with Director of Dietary (DD) # 219 verified the refrigerator has not been working since July 2025 and

the kitchen staff are continuously monitoring the temperatures but can only open the freezer door for short time periods to keep the temperatures in the freezer at appropriate levels. DD #219 stated the kitchen staff have been instructed not to keep eggs, raw meat, or dairy in the refrigerator but inside the freezer to keep food safer. DD #219 verified there were items in the refrigerator that could potentially spoil due to not being kept at a constant temperature. DD #219 stated the maintenance department has had several reports regarding the refrigerator but there is no plan in place for repairs. Interview on 08/20/25 at 10:00 A.M. with

the Regional Administrator verified the refrigerator was not maintaining the appropriate temperatures for food storage according to the facility's temperature logs and observations. Per the Administrator, there have been no residents exhibiting signs and symptoms of gastero-intestinal issues relating to food born illnesses.

This deficiency represents non-compliance discovered during the investigation for Complaint Number Event ID:

Facility ID:

If continuation sheet