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Complaint Investigation

Divine Rehabilitation And Nursing At Toledo

December 1, 2025 · Toledo, OH · 1011 North Byrne Road
Citations 2
Beds 93
Provider ID 366328
Healthcare Facility
Divine Rehabilitation And Nursing At Toledo
Toledo, OH  ·  View full profile →
Inspection Summary

DIVINE REHABILITATION AND NURSING AT TOLEDO in TOLEDO, OH — inspection on December 1, 2025.

Found 2 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.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Actual Harm

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Divine Rehabilitation and Nursing at Toledo

1011 North Byrne Road Toledo, OH 43607

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

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.


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