Divine Rehabilitation and Nursing at Toledo

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678May 22, 2025

  Based on closed medical record review, family interview, staff interview, review of staff statements and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) assistance for Resident #100, who was found unresponsive, absent of breaths, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code (full life-saving measures to be taken in the event of cardiac/respiratory arrest) status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when Licensed Practical Nurse (LPN) #300 responded to Resident #100's room and assessed the resident to be unresponsive and absent of vital signs. […]

• Immediate jeopardy, isolatedF689May 22, 2025

  Based on medical record review, staff interview, Carryout Attendant (CA) interview, review of facility video surveillance, and review of the facility policy, the facility failed to provide adequate supervision to ensure Resident #53, who had a diagnosis of schizoaffective disorder (a severe mental illness characterized by symptoms of schizophrenia, such as hallucinations and delusions, and a mood disorder), was assessed to be at risk for elopement, had a history of numerous elopement attempts, had a WanderGuard (wearable bracelet that triggers alarms at the doors to alert when a resident attempts to exit) applied to her wheelchair, and who was on 15-minute staff supervision checks, did not elope from the facility without staff knowledge. […]

• Actual harm, isolatedF550Dec 1, 2025

  Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure staff honored the rights of residents. This resulted in actual harm on 11/12/25 at 2:50 P.M. when Resident #145 expressed fear of a nurse and a concern for her health status after a nurse unexpectedly approached her and administered a second dose of the influenza vaccination in error, despite Resident #145 declining the shot and informing the nurse that she had already received the 2025 influenza vaccination. This affected one resident (#145) of three residents reviewed for resident rights. The facility census was 67.Review of Resident #145's medical record revealed an admission date of 10/14/25. […]

• Actual harm, isolatedF600Dec 1, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on medical record review, staff interviews, review of the facility incident investigation, review of video surveillance, review of employee personnel files, review of the facility self-reported incident (SRI), and review of facility policy, the facility failed to ensure residents were free from abuse. Actual harm occurred on 11/15/25 at 8:42 P.M. when Resident #169 was subjected to excessive physical force by a facility staff member, after which Resident #169 verbalized a fear for his safety, and being depressed at times with positive thoughts of self-harm. This affected one (#169) of three residents reviewed for abuse. […]

• Actual harm, isolatedF805Aug 20, 2025

  Based on medical record review, personnel file review, family interview, staff interview, and policy review, the facility failed to ensure a resident who was dependent on tube feeding and ordered nothing by mouth (NPO) was not served food to eat by a staff member. This resulted in actual harm when Resident #34 who was found choking on food after being served a dish of watermelon at the bedside and left alone to consume the watermelon. Subsequently, Resident #34 was sent to the hospital for invasive procedure to dislodge the food from the esophagus. Resident #34 was admitted to the hospital with aspiration pneumonia from choking and aspirating (breathing food into the lungs) on food. This affected one (Resident #34) of three residents reviewed for altered needs for dietary. […]