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Complaint Investigation

Divine Rehabilitation And Nursing At Toledo

October 27, 2025 · Toledo, OH · 1011 North Byrne Road
Citations 3
Beds 93
Provider ID 366328
Healthcare Facility
Divine Rehabilitation And Nursing At Toledo
Toledo, OH  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

DIVINE REHABILITATION AND NURSING AT TOLEDO in TOLEDO, OH — inspection on October 27, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0684
Quality of Life and Care Deficiencies

hold the resident's medication, as instructed. Resident #56's bone marrow biopsy had to be

10/07/25, and 10/08/25.

Interview with Licensed Practical Nurse (LPN) #305 on 10/20/25 at 11:56

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.

366328 10/27/2025

Divine Rehabilitation and Nursing at Toledo 1011 North Byrne Road Toledo, OH 43607

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 2630303.

366328 10/27/2025

Divine Rehabilitation and Nursing at Toledo 1011 North Byrne Road Toledo, OH 43607

the kitchen, with a recommendation to clean and sanitize the area; and on 08/15/25, overgrown

actions.Review of a Commercial Services Agreement Addendum, dated 10/09/25, revealed the pest

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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TOLEDO, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DIVINE REHABILITATION AND NURSING AT TOLEDO or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.