Divine Rehabilitation And Nursing At Toledo

F 0550 Level of Harm - Actual harm Residents Affected - Few

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

was on the phone per video at the time of the incident, knew what they were talking about, at which time RN #590 came up behind Resident #145 and poked the resident in the right arm with the vaccination.

Interview with the Administrator on 11/24/25 at 12:22 P.M. verified RN #590 administered the influenza vaccination to Resident #145 against her will and also verified the medication error occurred when RN #590 administered the influenza vaccination, instead of the pneumococcal vaccination. The Administrator confirmed Resident #145 received two influenza immunizations this season and should not have. Interview with Resident #145 on 12/01/25 at 11:50 P.M. revealed she decided to receive the influenza vaccination in October 2025, and it was administered. Resident #145 voiced concern that the influenza vaccination was administered again and against her will in November 2025. Resident #145 stated on 11/12/25 RN #590 entered her room and informed her she was to receive an influenza vaccination. Resident #145 stated she verbally refused the immunization and informed RN #590 that she previously received the vaccination. RN #590 told Resident #145 that she did not know what she was talking about at which time RN #590 came up behind Resident #145 and injected the immunization into her right arm. Resident #145 said she reported

the nurse to administration. Resident #145 stated she is now afraid of RN #590, while the nurse no longer provides her care she is still in the building and provides care to other residents. Resident #145 also voiced concerns for her health due to receiving two influenza vaccinations a month apart. Interview with Certified Nurse Practitioner (CNP) #600 on 12/01/25 at 12:02 P.M. revealed she was aware Resident #145 received two influenza vaccinations. CNP #600 did see Resident #145 after being made aware of the administration of a second influenza vaccination and had no health concerns. Review of the undated facility policy titled General Immunization/Vaccination revealed residents, staff members, and volunteer workers retain the right to refuse immunizations. Review of the undated facility policy titled Medication Administration stated medications are to be administered as ordered by the physician and in accordance with professional standards of practice. Review of the undated facility policy titled Abuse, Neglect, and Exploitation revealed abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. This deficiency represents non-compliance investigated under Complaint Numbers 2676384 and 2670000.

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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

12/01/2025

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 0600 Level of Harm - Actual harm Residents Affected - Few

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

the Human Resources Director. - On 11/16/25, the Administrator notified the Medical Director of the incident between LPN #800 and Resident #169.- On 11/16/25 at 12:25 P.M., the Administrator reported the incident to the state agency. (SRI #267611).- On 11/16/25, the DON assessed Resident #169 with no injuries noted.- On 11/16/25, the DON/designee conducted resident interviews for all interviewable residents to ensure they felt safe in the facility. Interviews revealed no other concerns about safety.- On 11/16/25, the DON/designee conducted skin assessments on all non-interviewable residents with no negative findings.- On 11/16/25, the Administrator reviewed the two-minute video footage of the incident dated 11/15/25 and timed at 8:22 P.M.- On 11/16/25, the Administrator interviewed Residents #138 and #145 who were sitting near Resident #169 in the video.- On 11/16/25, the Administrator completed staff interviews with CNA #605, CNA #712, LPN #572, LPN #800, and LPN #801.- On 11/16/25, the Administrator suspended LPN #800 and LPN #801.- On 11/17/25, Resident #169 was evaluated by psychiatry.- On 11/17/25, the DON touched base with Resident #169 and the resident indicated he did not feel safe in the facility. The DON offered a continuous one-to-one with an aide and Resident #169 agreed.

An aide was placed to directly observe Resident #169.- On 11/17/25, Resident #169 was assessed by Social Services #554 with no additional concerns identified. Resident #169 was notified of the level of care paperwork being finalized for the transfer to another facility. Resident #169 had been accepted at another facility prior to the incident.- On 11/17/25, all staff were educated by Staff Development Coordinator #507

on abuse, neglect, exploitation, and timely reporting abuse.- On 11/17/25, the MDS Coordinator reviewed and updated Resident #169's care plan to reflect the trauma related to physical abuse.- On 11/17/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the incident and

the action plan.- On 11/18/25, a police report was filed by the Administrator.- On 11/18/25, Resident #169 remained on direct observation.- On 11/18/25, Resident #169 was accepted to be admitted to another facility. Social Services #554 notified Resident #169 and made transportation arrangements. - On 11/19/25, all staff were educated on resident rights and smoking regulations by Staff Development Coordinator #507.On 11/19/25, the Administrator terminated LPN #801 and LPN #800 for violation of company policy.- On 11/19/25, Resident #169 remained on direct observation.- On 11/19/25 at 1:30 P.M., Resident #169 was discharged from the facility. Resident #169 was in his electronic wheelchair and had all personal items.- On 11/20/25, a monthly QAPI meeting was held with a review of the incident and actions taken presented.- On 11/21/25 at 3:32 P.M., the Administrator closed the SRI. This deficiency represents non-compliance investigated under Complaint Numbers 2660931 and 2670000.

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