Divine Rehabilitation And Nursing At Toledo

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

to be canceled as the facility provided the resident breakfast that morning. The procedure was rescheduled for 10/09/25. On 10/08/25, RN #200 stated she contacted the facility to ensure pre-procedure instructions were followed, including the holding of Eliquis and aspirin for three days prior to the procedure, and discovered the facility did not hold the resident's medication, as instructed. Resident #56's bone marrow biopsy had to be rescheduled for a second time due to the facility not following pre-procedure orders.

Additional review of the October 2025 MAR confirmed Resident #56 was administered aspirin and Eliquis

on 10/06/25, 10/07/25, and 10/08/25. Interview with Licensed Practical Nurse (LPN) #305 on 10/20/25 at 11:56 A.M. revealed that when a resident returned to the facility with new orders for a procedure, the information was placed in the MAR, and the physician was notified. LPN #305 stated the facility did not have hard/paper charts, so there were delays in uploading important documents into the electronic medical

record (EMR). LPN #305 stated report between nurses was verbal, and they had a report sheet. LPN #305 confirmed Resident #56 ate before his appointment on 10/01/25, and that the second appointment on 10/09/25 was cancelled due to staff administering aspirin and Eliquis to Resident #56, and not holding it for three days prior, as instructed. Interview with Director of Nursing (DON) on 10/20/25 at 2:25 P.M. revealed

the floor nurse would have been the staff who received the orders for Resident #56's bone marrow biopsy preparation. The DON confirmed that there were no orders in the EMR for the pre-procedure instructions for

the bone marrow biopsy scheduled for 10/01/25, resulting in staff providing the resident breakfast on 10/01/25 and cancellation of the procedure. The DON further verified pre-procedure instructions were not followed for the bone marrow biopsy scheduled for 10/09/25 and the staff administered Resident #56's Eliquis and aspirin, resulting in the procedure being rescheduled for 10/21/25. The DON stated dietary staff were verbally informed of any NPO orders, but there should be a more formal process in place to avoid potential issues, like in the case with Resident #56 being served his breakfast meal on 10/01/25. Interview with RN Unit Manager (RN/UM) #306 on 10/22/25 at 2:47 P.M. revealed when a resident returned from an appointment, the nurse received the after-visit packet. The nurse providing care for the resident was supposed to review the information and enter any new orders into the EMR. RN/UM #306 confirmed this was not completed for Resident #56's procedures. This deficiency represents non-compliance investigated under Master Complaint Number 2639137.

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

10/27/2025

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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

and the right heel was rewrapped with gauze. Review of a nursing progress note dated 09/27/25 at 7:34 A.M. revealed the nurse spoke with an ED nurse who reported that Resident #71 seemed confused, and

they had found six maggots in the resident's wound. Interview on 10/21/25 at 3:24 P.M. with the facility's wound care nurse, LPN #303, revealed Resident #71 admitted to the facility with multiple wounds. LPN #303 stated Resident #71 received skin prep daily to the right heel due to the heel being soft. LPN #303 verified the facility had no evidence the right heel wound was being monitored or assessed from the time of admission on [DATE REDACTED] until the resident was seen by the wound care physician on 09/15/25, and further confirmed nursing should have monitored and assessed the area. LPN #303 stated that on 09/11/25, a nurse aide reported that she attempted to remove Resident #71's sock and the resident's skin began to peel off with the sock. LPN #303 stated she removed the sock, which exposed a large open area to the resident's right heel. LPN #303 stated she called the wound physician, received new orders, and Resident #71 was going to be further evaluated by the physician the following day. LPN #303 confirmed she did not document an assessment of the wound on 09/11/25 and the facility had no evidence the treatment ordered

on 9/11/25 was initiated until 09/13/25. A follow-up interview on 10/23/25 at 9:34 A.M. with wound nurse LPN #303 confirmed skin checks were supposed to be conducted weekly, and these were usually set up by

the unit managers on a resident's shower day. LPN #303 verified Resident #71 did not have any orders for weekly skin checks and further confirmed the facility had no evidence weekly skin checks were completed from 08/22/25 until 09/24/25. Additionally, LPN #303 verified that the skin checks that were completed on 08/08/25, 08/15/25, 08/22/25, and 09/24/25 failed to identify and assess the wound to Resident #71's right heel. LPN #303 further verified that the facility did not have evidence skin prep to Resident #71's right heel was completed on 08/14/25, 08/15/25, 08/20/25, 09/01/25, 09/04/25, and 09/10/25 and no documentation of offloading pressure boots being in place on 08/06/25 at night, 08/14/25 and 08/15/25 during the day, 08/16/25 at night, and 08/20/25 during the day.Interview on 10/23/25 at 10:29 A.M. with Wound Physician (WP) #400 revealed Resident #71 was seen last on 09/22/25, and the wound on the heel was debrided (not documented in the wound care notes). WP #400 stated Resident #71 most likely had a deep tissue injury

on the right heel prior to its opening. WP #400 stated the staff should have been applying the skin prep to

the right heel and allowing it to completely air dry before putting socks back on, and, most likely what happened was the skin prep did not completely dry and the sock stuck to the heel, removing a layer each time his socks were removed. WP #400 stated necrosis can set in within a couple of hours, if not properly treated. WP #400 stated Resident #71 may have had slough (buildup of dead tissue) on his right heel upon admission and could not recall any assessment or monitoring of the right heel, or any treatments other than skin prep and offloading boots. Interview on 10/23/25 at 2:00 P.M. with the Administrator confirmed that weekly skin checks should have been completed by nursing for Resident #71 and further confirmed that the skin checks that were documented included no mention of skin issues to the resident's right heel. Review of

the facility policy titled, Wound Treatment Management, dated 2024, revealed treatments would be documented on the treatment administration record in the electronic health record. The effectiveness of treatments would be monitored through ongoing assessment of the wound. Considerations for needed modifications included lack of progression towards healing, and changes in the characteristics of the wound. This deficiency represents noncompliance investigated under Complaint Numbers 2636464 and

1. 2630303. 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

10/27/2025

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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

and a treatment was completed. Additional review of the open actions from previous service section revealed on 12/13/24, door gaps were noted with a recommendation to add/repair door sweeps on the common area doors; on 01/10/25, a water leak was identified in the kitchen with a recommendation to repair the leak; on 01/10/25, debris was present in the kitchen, with a recommendation to clean the area; on 04/11/25, debris was present in the kitchen, with a recommendation to clean and sanitize the area; and on 08/15/25, overgrown vegetation was noted on the exterior of the building, with a recommendation to cut the vegetation for insect and rodent control. The customer (facility) was identified as the responsible party for

the open actions.Review of a Commercial Services Agreement Addendum, dated 10/09/25, revealed the pest control vendor provided an estimate for additional services to treat rats and mice. The scope and nature of the work was rodent repellent service. The agreement was not signed by the facility.Review of the pest control service report dated 10/10/25 revealed a monthly standard service was completed. Further

review revealed a pipe leak was observed, causing gnats. It was recommended that the pipe be repaired and the kitchen be cleaned. When inspecting the bait stations, a dead mouse was found in the one by the front door. Additional review of the open actions from the previous services section revealed on 12/13/24, door gaps were observed, and it was recommended to add/repair door sweeps and on 08/15/25, overgrown vegetation was recommended to be cut down on the exterior of the building to control insects and rodents.

The customer (facility) was identified as the responsible party for the open actions.Review of the facility policy titled, Pest Control Program, dated 2025, revealed it was the policy of the facility to maintain and effective pest control program that eradicated and contained common household pests and rodents.

Further review revealed appropriate chemicals were used to control pests but could be used safely inside

the building without compromising residents' health. The facility would maintain a report system of issues that may arise between scheduled visits with the outside pest service and treat as indicated. The facility would utilize a variety of methods in controlling certain seasonal pests, such as flies. These would involve indoor and outdoor methods that were deemed appropriate by the outside pest service and state and federal regulations.This deficiency represents non-compliance investigated under Complaint Number 2630302 and 2636464.

Event ID:

Facility ID:

If continuation sheet