Divine Rehabilitation and Nursing at Sylvania

In the surveyor’s words

From the most serious findings on record at Divine Rehabilitation and Nursing at Sylvania, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 15, 2024

  Based on observations, medical record review, review of hospital medical records, review of the emergency department record, review of the Abuse/Neglect policy and procedure, review of the Wound Treatment Management policy, review of the Skin Assessment policy, resident interview, Medical Director interview and staff interviews, the facility failed to ensure Resident #59, who was admitted to the facility on hospice care, was free from a situation of neglect when facility staff failed to provide ongoing wound assessments, care and services to prevent a significant decline in a wound, and notification to the physician when there was a decline in the wound. […]

• Immediate jeopardy, isolatedF678Mar 4, 2024

  Based on medical record review, staff interviews, review of the facility investigation, review of a personnel file, review of an emergency medical services (EMS) run report, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPNs), and review of the cardiopulmonary resuscitation (CPR) certifications, the facility failed to timely initiate CPR for one resident (Resident #05) found unresponsive, without a pulse or blood pressure, and who was identified as a Full Code status. […]

• Immediate jeopardy, isolatedF689Nov 14, 2022

  Based on medical record review, observation, resident interviews, staff interviews, community member interviews, review of the facility's Self-Reported Incident (SRI), review of the facility's investigations, review of a police incident detail report, review of maintenance exit door operation tests, and review of facility polices regarding elopement, wandering residents, and resident alarms, the facility failed to provide adequate supervision for Resident #10, who was at risk for wandering and had a history of wandering/elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #10 eloped from the facility, without staff knowledge, and the facility staff failed to respond appropriately. […]

• Actual harm, isolatedF686Mar 10, 2025

  Based on observation, interviews with facility staff and the wound physician, review of the medical record, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to ensure a resident's skin impairment was identified timely and a treatment initiated. This resulted in Actual Harm to Resident #68 on 01/30/25 when the facility failed to assess a resident's wound and obtain physician orders for wound treatments resulting in Resident #68 developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) requiring debridement. This affected one (#68) of two residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF600Oct 10, 2023

  Based on medical record review, Self-Reported Incident review, hospital record review, staff interview, and policy review, the facility failed to prevent an incident of resident-to-resident abuse with injury. This resulted in actual harm when Resident #23 was found on top of Resident #12, punching him and bit the tip of Resident #12's finger off. Subsequently, requiring Resident #12 to have surgical interventions to reattach the fingertip, pain medication and antibiotic therapy. This affected one (Resident #12) of three resident reviewed for potential abuse. The facility census was 92. Findings included: Review of Self-Reported Incident Number 229152 dated 09/14/23 revealed both patients (Resident #12 and Resident #23) were roommates and resided in the memory care unit. […]