Inspection·November 6, 2023

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure newly admitted residents were seen and evaluated by a physician within the first 30 days of admission. This affected three (Residents #10, #19, and #23) of 17 residents reviewed for physician services. The facility census was 83. Residents Affected - Few Findings include: 1. Review of Resident #10's medical record revealed an admission date of 09/16/23 and a discharge date of 10/31/23. Diagnoses included kidney cancer, bone cancer, type II diabetes, major depressive disorder, chronic kidney disease, and chronic right humerus fracture. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of Resident #10's Physician Visit notes revealed Resident #10 was seen by the Nurse Practitioner on 09/26/23, 10/03/23, 10/05/23, 10/06/23, and 10/10/23. No visits from the physician were found. There was no evidence in Resident #10's medical record that Resident #10 was evaluated by a physician during the resident's stay at the facility from 09/16/23 to 10/31/23. Interview on 11/06/23 at 7:42 A.M. with the Director of Nursing (DON) verified Resident #10 was only seen by the Certified Nurse Practitioner and not the physician in the time Resident #10 resided in the facility. 2. Review of Resident #23's medical record revealed an admission date of 09/15/23. Diagnoses included altered mental status, type II diabetes, epilepsy, Alzheimer's disease, and bipolar disorder. Review of Resident #23's MDS assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Review of Resident #23's Physician/ Nurse Practitioner Medical Visit forms revealed Resident #23 was seen by the Nurse Practitioner (NP) on 09/26/23, 09/29/23, 10/03/23, and 10/10/23. Resident #23 was not documented as being seen by the physician. There was no evidence in Resident #23's medical record that Resident #23 was evaluated by a physician from 09/15/23 to 11/05/23. Interview on 11/06/23 at 3:10 P.M. with the Director of Nursing verified Resident #23 was not seen by the physician within the first 30 days of admission and was only seen by the Nurse Practitioner. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365898 Printed: 05/15/2026 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 365898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Sylvania 5757 Whiteford Rd Sylvania, OH 43560 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)