Inspection visit
Inspection
48 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 48 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, staff interview, record review and review of policy, the facility failed to
ensure residents were treated in a dignified manner. This affected two residents (#14 and #79) of four
residents reviewed for dignity. The facility identified 18 resident smokers. The facility census was 85.
Findings include:
1. Review of the medical record for Resident #14 revealed an admission date of 05/13/20, with diagnoses
including cerebral infarction, anemia, hypertension, congestive heart failure, and chronic respiratory failure.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had
cognitive impairment and required substantial assistance for bed mobility.
Observation on 11/13/23 at 11:29 A.M. revealed no linens on the bed of Resident #14, a bath blanket was
underneath the middle section of Resident #14's body.
Interview on 11/13/23, at the time of observation, with Resident #14 revealed the bed linens had been
removed from the bed during the night when Resident #14 received a bath, and a bath blanket was placed.
Resident #14 requested sheets be placed on the bed and was told day shift will take care of it.
Interview on 11/13/23 at 11:55 A.M., with State Tested Nursing Assistant (STNA) #221 verified Resident
#14 did not have sheets on the bed.
Review of the undated policy titled Activities of Daily Living, stated residents unable to carry out activities of
daily living will receive the necessary services.
2. Review of the medical record for Resident #79 revealed an admission date of 05/12/23, with diagnoses
including hypertension, nontraumatic intracerebral hemorrhage, schizoaffective disorder, and tobacco use.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had moderate
cognitive impairment and is independent with mobility.
Review of the smoking safety screen completed on 10/20/23 revealed Resident #79 had cognitive
impairment, smokes five to ten cigarettes per day and smokes morning, afternoon, evening, and nights and
(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 53
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
11/16/2023
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)
F 0550
required supervision for smoking.
Level of Harm - Minimal harm
or potential for actual harm
Review of the care plan dated 05/26/23 revealed Resident #79 was a smoker, interventions included the
resident to be instructed about smoking risks and hazards, facility policy on smoking, locations, times, and
safety concerns and for the resident to have supervision with smoking.
Residents Affected - Few
Observation of smoking break on 11/14/23 at 10:30 A.M., revealed Resident #79 approached Registered
Nurse (RN) #190 and requested a cigarette to go outside to join the other residents already outside for
supervised smoking. RN #190 refused to provide Resident #79 a cigarette due to behaviors.
Interview on 11/14/23 at 10:35 A.M., with Resident #79 revealed RN #190 refused to provide a cigarette
upon request.
Interview on 11/14/23 at 12:30 P.M., with RN #190 verified she refused to provide Resident #79 a cigarette
upon request at the 10:30 A.M. smoking session due the smokers already being outside.
Review of the undated policy titled Resident Smoking, stated any resident deemed safe to smoke, with or
without supervision, will be allowed to smoke in designated smoking areas, at designated times, and in
accordance with the care plan.
Review of the undated policy titled Resident Rights, stated residents have the right to a dignified existence,
to be treated with respect and dignity, and the right to receive services in the facility with reasonable
accommodation of resident needs and preferences.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 2 of 53
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
11/16/2023
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)
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interview and policy review, the facility failed to ensure call lights were
within reach and accessible. This affected two (#9 and #39) of 25 residents reviewed for call light
placement. The facility census was 85.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #9 revealed an admission date of 01/01/23, with diagnoses
including chronic obstructive pulmonary disease, hypertension, type II diabetes mellitus, peripheral
autonomic neuropathy, depression, and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was
cognitively intact, was dependent for mobility with limited range of motion to the right upper extremity due to
a contracture for which a right resting hand splint with separators was worn at night for contracture
management.
Observation on 11/13/23 at 11:15 A.M., revealed Resident #9 lying in bed watching television with the over
bed table to the right of the resident, the call light was not within reach and hanging below the level of the
mattress on the right upper side rail above the head of the resident.
Interview on 11/13/23 at 1:20 P.M., with State Tested Nurse Aide (STNA) #203 verified Resident #9's call
light was out of reach and further verified Resident #9 would be able to use the call light if the call light was
within reach.
2. Review of Resident #39's medical record revealed an admission date of 08/07/23, with diagnoses
including cerebral infarction, type II diabetes mellitus, acute respiratory failure with hypoxia, hypertension,
chronic kidney disease, bell's palsy, and hemiplegia to the left, non dominant side.
Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had
moderate cognitive impairment required the extensive assistance of two staff for bed mobility, and transfers.
Observation on 11/13/23 at 1:00 P.M., revealed Resident #39 was lying in bed, facing left with eyes open.
The call light was noted to be stuffed between mattress and right upper side rail, below the level of the
mattress and out of the reach of Resident #39.
Interview on 11/13/23 at 1:20 P.M., with STNA #203 verified the call light was out of reach and Resident
#39 would be able to use the call light if it was within reach.
Review of the undated policy titled Call Lights: Accessibility and Timely Response, stated staff will ensure
the call light is within reach of resident and secured, as needed with the call light accessible to residents
while in their bed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 3 of 53
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
11/16/2023
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)
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, resident interview and staff interview, the facility failed to ensure
residents were provided with opportunities and assistive devices for out of bed activity. This affected one
(#73) of 24 residents reviewed for the provision of choices. The facility census was 85.
Findings include:
Review of Resident #73's medical record revealed an admission date of 02/27/23, with the diagnosis
including left hemiplegia, alcoholic cirrhosis, cerebral infarction, pyogenic arthritis, malnutrition, pain in right
shoulder and left hip, anemia, atrial fibrillation, congestive heart failure, and urinary retention. Review of the
minimum data set assessment dated [DATE] assessed Resident #73 with the ability to make needs known,
intact cognition, no recorded refusal of care, range of motion impairment limitation to lower extremity,
dependent on staff for activities of daily living including bed mobility and transfer, incontinent of bowel and
bladder, received a mechanically altered diet, and at risk for pressure ulcer development.
Review of the nursing plan of care revealed on 10/11/23 the plan was revised to address Resident #73
activity of daily living self-care performance deficit related to activity intolerance, confusion, fatigue,
hemiplegia, impaired balance, limited mobility. Interventions included transfer utilizing two staff via a
mechanical lift due to total dependence and uses high back reclining chair (Geri-chair) for mobility as
needed.
Observations of Resident #73 were as follows: 11/14/23 at 9:47 A.M., 10:26 A.M., 1:15 P.M.; 11/15/23 at
6:41 A.M., 12:50 P.M.; and 11/16/23 at 6:50 A.M., noted the resident in bed wearing a hospital gown.
Interview with Resident #73 stated he would like the opportunity to be out of bed. However, the only time he
is out of bed is during showers.
Interview on 11/15/23 at 12:51 P.M., with State Tested Nurse Aides (STNA) #191 and STNA #164 were
identified as being assigned to Resident #73 for the provision of daily care. Both STNAs indicated they have
provided Resident #73 with daily care since May 2023, when the resident was moved to a room on their
assigned unit. The STNAs revealed Resident #73 has not had a chair or wheelchair since he was admitted
to the unit and the only time, he is out of bed is for a shower twice a week. The STNAs stated Resident #73
is dependent on all care and would require the use of a mechanical lift, and a high back reclining chair
(Geri-chair) due to restricted lower extremity mobility.
Additional review of the medical record confirmed Resident #73 was moved to the current room on
05/18/23.
Interview on 11/15/23 at 2:14 P.M., with the Director of Nursing (DON), during review of Resident #73
medical record, confirmed the resident's plan of care indicates the use of a Geri-chair as needed. The DON
unaware Resident #73 was not given out of bed opportunities daily.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 4 of 53
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
11/16/2023
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)
F 0567
Honor the resident's right to manage his or her financial affairs.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, record review, resident interviews, staff interviews, and policy review, the facility
failed to ensure residents had daily access to their resident fund accounts. This had the potential to affect
54 (#1, #2, #3, #4, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #28,
#29, #30, #31, #36, #37, #38, #40, #43, #44, #45, #46, #48, #50, #51, #53, #55, #56, #60, #61, #62, #65,
#66, #69, #71, #72, #73, #74, #77, #78, #81, #82, and #388) of 54 residents with an open resident fund
accounts. The facility census was 85.
Residents Affected - Some
Findings include:
Observation on 11/13/23 at 8:10 A.M., revealed the facility had a pink sign on the front desk stating,
Banking hours 8:30 to 4:30.
Review of the facility provided list revealed 54 (#1, #2, #3, #4, #6, #8, #11, #12, #13, #14, #15, #16, #17,
#18, #19, #20, #21, #22, #23, #24, #25, #28, #29, #30, #31, #36, #37, #38, #40, #43, #44, #45, #46, #48,
#50, #51, #53, #55, #56, #60, #61, #62, #65, #66, #69, #71, #72, #73, #74, #77, #78, #81, #82, and #388)
residents had personal funds accounts.
Interviews on 11/13/23 from 10:38 A.M. to 2:50 P.M., with Resident #20 and #21 revealed the residents
cannot get access to their money on the weekends. Resident #20 revealed he wanted to be able to get his
funds and was told he needed to wait until business hours open.
Interview on 11/14/23 at 4:18 P.M., with Receptionist #219 revealed the facility had set banking hours:
Monday through Friday from 8:30 A.M. to 4:30 P.M. and revealed the residents coming to the front desk and
request money from her that gets taken from their personal fund account. Receptionist #219 revealed the
facility did not have a process in place for staff on evenings and weekends to be able to get residents cash
from the petty cash box outside of their bank hours.
Interview on 11/15/23 at 3:00 P.M., with Business Office Manager (BOM) #300 revealed a previous
Administrator had made the change as staff were not properly filling out receipts. BOM #300 revealed the
residents at the time were agreeable but revealed it occurred several months ago. BOM #300 revealed she
was unaware of any regulation requiring residents to get timely or same day access to their funds as
requested.
Review of the policy titled Resident Personal Funds, dated 2023 revealed the residents had the right to
manage their financial affairs. The policy did not include any language regarding access to funds.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 5 of 53
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
11/16/2023
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)
F 0571
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Limit the charges against residents' personal funds for items or services for which payment is made under
Medicare or Medicaid.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident interview, staff interview and policy review, the facility failed to ensure they received
approval in writing to access personal funds and keep the Medicaid regulated $50 each month for a
Medicaid resident. This affected one (#22) of five residents reviewed for resident funds. The facility census
was 85.
Findings include:
Review of the medical record for the Resident #22 revealed an admission date of 05/04/22, with diagnoses
including femur fracture, vascular leuko encephalopathy, Alzheimer's disease, diabetes, and dementia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively
impaired with a Brief Interview for Mental Status (BIMS) of 2 and required extensive assistance of one to
two staff for mobility. The score is as follows: 13-15 = cognitively intact, 8-12 = moderately impaired, and 0-7
= severe impairment.
Review of the BIMS assessments dated 05/08/22 to 11/07/23 revealed the resident's BIMS score ranged
from one to three, with an admission BIMS cognitive assessment on 05/04/23 of eight.
Review of the personal fund quarterly statements dated January 2023 to September 2023 revealed the
facility took out from resident's account the entirety of her social security check including the $50 that
Medicaid Residents get to keep from February 2023 through August 2023.
Interview on 09/15/23 at 9:50 A.M., with the Administrator revealed the resident was agreeable and signed
off on the facility using her $50 per month income to pay her outstanding balance. The Administrator
revealed she was unaware of Resident #22 having a low BIMS and being unable to authorize or understand
this decision.
Interview on 11/15/23 around 2:30 P.M., with Resident #22 revealed she was not alert and oriented and
revealed she was unable to answer any of the surveyor questions with appropriate responses.
Interview on 11/15/23 at 3:00 P.M., with Business Office Manager #300 revealed the facility had no
evidence in writing that resident was aware or agreeable to facility taking all of her $50 dollars each month
from February 2023 to July 2023 to pay off her debts at the facility.
Review of the policy titled Resident Personal Funds, dated 2023, revealed the residents had the right to
manage their financial affairs and include the right to know in advance what charges a facility may impose
against a residents' personal funds. The policy did not include any language regarding informing residents
in writing of any charges being taken from their fund accounts.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 6 of 53
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
11/16/2023
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)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and policy review, the facility failed to ensure resident's advanced
directives were clearly described and contained in medical records. This affected three (#33, #68, #81) of
24 residents reviewed for advanced directives and code status choices. The facility census was 85.
Findings include:
1. Review of Resident #33's medical record revealed an admission date on 06/05/23, with diagnoses
including cerebral infarction, congestive heart failure, and hypertension. Review of the minimum data set
assessment dated [DATE] assessed Resident #33 with severe cognitive impairment, sometimes
understands or is understood, moderately impaired vision without corrective lenses, hearing deficit, and
required partial to moderate staff assistance to complete hygiene task and activities of daily living.
Review of the medical record revealed on 06/06/23, a physician order was implemented for Advanced
Directive: Do Not Resuscitate Comfort Care (DNRCC) DNRCC. No directions specified for order.
Review of the form titled Do Not Resuscitate Comfort Care (DNRCC) Identification contained in Resident
#33 medical record, the form was signed by the physician on 06/23/23. Two boxes indicating choices were
noted on the form. One box included DNRCC and noted if this box is checked, the DNR Comfort Care
Protocol is activated immediately. The second box revealed DNRCC-ARREST and noted if this box is
checked, the DNR Comfort Care Protocol is implemented in the event of a cardiac arrest or a respiratory
arrest. However, no choice was selected indicating the resident requested directive of DNRCC or
DNRCC-Arrest.
Review of the nursing plan of care revealed the plan was developed on 08/08/23 to address Resident #33's
Do Not Resuscitate Comfort Care code status. Intervention included respect and honor resident request
and wishes during stay. No further interventions address type or level of care related to code status.
Interview on 11/16/23 at 8:50 A.M., with the Director of Nursing, during review of Resident #33's medical
record confirmed an electronic order dated 06/06/23 for DNRCC. However, review of DNRCC Identification
Form dated 06/23/23 signed by the physician lacks DNRCC or DNRCC Arrest choice regarding type of
DNRCC selected.
2. Review of Resident #68's medical record revealed an admission date of 08/03/22, with the diagnoses
including rhabdomyolysis, osteoporosis with pathological vertebra fracture, chronic obstructive pulmonary
disease, depression, anxiety, and vitamin d deficiency. Review of the minimum data set assessment dated
[DATE], revealed Resident #68 was assessed with moderate cognitive impairment, requires set-up assist
with activities of daily living, independently mobile utilizing a walker.
Review of the medical record revealed on 08/09/22, a physician order was implemented for Advanced
Directive: Do Not Resuscitate Comfort Care (DNRCC). No directions specified for order.
Further review of the medical record lacked the Do Not Resuscitate Comfort Care (DNRCC) Identification
form signed by the physician indicating Resident #68 choice of DNRCC or DNRCC-ARREST.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 7 of 53
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
11/16/2023
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)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the nursing plan of care revealed the plan was developed on 11/15/22 to address Resident #68
Do Not Resuscitate Comfort Care code status. Intervention included respect and honor resident request
and wishes during stay. No further interventions address type or level of care related to code status.
Interview on 11/16/23 at 11:35 A.M., with Director of Social Services #132 verified Resident #68 medical
record did not contain a DNRCC identification form to designate resident code status selection of DNRCC
or DNRCC-Arrest choices.
3. Review of the medical record for Resident #81 revealed an admission date of 09/01/23, with diagnoses
including hypertension, dementia, glaucoma, cataract, and insomnia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was
cognitively impaired.
Review of the current physician orders revealed an order dated 09/02/23 for an advance directive which
stated Resuscitate (cardiopulmonary resuscitation) and an order dated 09/08/23 for a Do Not Resuscitate,
Comfort Care (DNR CC).
Review of the baseline care plan dated 09/02/23 and review of the comprehensive care plan dated
09/06/23 and revised on 09/08/23, 11/10/23 and 11/14/23 revealed Resident #81 was a full code
(Resuscitate).
Review of the care conference notes dated 09/05/23 and timed 10:33 A.M., revealed Resident #81 was a
full code but would like more information on DNR CC status and the Nurse Practitioner was notified of the
request.
Interview on 11/14/23 at 1:54 P.M., with Licensed Practical Nurse (LPN) #112 revealed Resident #81 was a
full code. Further review of the current physician orders for Resident #81 with LPN #112, during the
interview, verified Resident #81 had a full code and DNR-CC order. LPN #112 stated that is confusing and
needs clarification.
Review of the undated policy titled Residents' Rights Regarding Treatment and Advanced Directives, stated
the facility is to support and facilitate a resident right to request, refuse and or discontinue medical or
surgical treatment and to formulate an advanced directive. An Advanced Directive is written instruction,
such as a living will or durable power of attorney for health care, recognized under State law relating to the
provision of health care when the individual is incapacitated. Upon admission, should the resident have an
advanced directive, copies will be made and placed on the chart as well as communicated to the staff.
During the care planning process, the facility will identify, clarify, and review with the resident or legal
representative whether they desire to make any changes related to any advanced directives.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 8 of 53
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
11/16/2023
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)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, Power of Attorney (POA) interview, staff interview, and policy review, the facility failed to
ensure the physician and family were contacted after a change in condition with acute pain was identified.
This affected one (#47) of two residents reviewed for a change in condition. The facility census was 85.
Findings include:
Review of the medical record for Resident #47 revealed an admission date of 05/19/20, with diagnoses
including chronic obstructive pulmonary disease, heart failure, muscle weakness, depression insomnia,
Review of the emergency contact list revealed Resident #47 had a friend listed at the emergency contact
with notation of being the healthcare and financial power of attorney as well as a daughter and brother
listed as additional contacts.
Review of the physician orders dated 10/07/20 revealed an order for Tylenol tablet (acetaminophen) with
instructions to given one tablet, 650 milligrams (mg) by mouth every 6 hours as needed for pain.
Review of the Medication Administration Record (MAR) dated August 2023 revealed the resident's pain had
been monitored twice daily. Resident #47 reported pain at 2/10 on one of 62 assessments, 3/10 on four of
62 assessments and all other assessments were zero of 10 or marked as not applicable. The MAR also
reported Resident #47 received one dose of Tylenol this month on 08/07/23 at 5:24 P.M.
Review of the progress notes dated 09/04/23 at 8:25 A.M. revealed the resident complained of pain to the
right leg. Resident #47 was unable to lift the right leg upon being assessed the resident could not lift the left
leg. Resident #47 stated I felt it a few days ago and it hurts 8/10 pain scale. Review of progress note dated
09/05/23 at 2:30 P.M., revealed a STNA had found resident on the floor near the bathroom door with his
cane. Resident #47 stated he was trying to get to the bathroom. Resident #47 was assessed, and vitals
were within normal limits and resident complained of pain of the right leg and right hip. Resident #47 was
sent to the hospital for evaluation. A progress note dated 09/05/23 at 7:51 P.M., revealed the hospital
informed staff resident was being admitted with diagnosis for right hip fracture.
Review of the Medication Administration Record (MAR) dated September 2023 revealed residents pain had
been monitored two to three times daily. In 09/2023 Resident complained of pain 5/10 once on 09/03/23,
09/04/23 and again 09/05/23. The MAR also reported Resident received one dose of Tylenol 09/03/23 at
3:14 P. M. and one dose on 09/05/23 at 10:49 A.M.
Review of the fall investigation dated 09/05/23 revealed a fall occurred 09/05/23 in the resident's room
outside the bathroom. The investigation found a rug in front of the sink outside the bathroom to be a
possible cause.
Review of the History and Physical from the hospital dated 09/05/23 revealed x-ray results from an x-ray of
right femur revealed a displaced fracture of trochanter. Review of hospital orthopedic
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 9 of 53
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
11/16/2023
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)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
consult note dated 09/05/23 revealed the hospital plan to treat non-operatively, with pain management and
Physical and Occupational therapy evaluation.
Review of Hospital progress note dated 09/07/23 revealed the resident had sustained an injury from fall
which was an acute displaced hip fracture of the greater trochanter.
Residents Affected - Few
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had significant
cognitive impairment and required limited one person assist for transfers.
Review of the plan of care dated 10/26/23 revealed Resident #47 was on pain medication related to
generalized pain with interventions to administer medications as ordered by physician and
monitor/document side effects and effectiveness and monitor for increased risk of falls. The care plan had a
second section related to pain with additional interventions to anticipate residents need for pain relief and
respond immediately to any complaint of pain and identify and record previous pain history and
management of that pain and impact on function and identify previous response to pain relief.
Interview on 11/15/23 at 8:46 A.M., with Unit Manager Licensed Practical Nurse (LPN) #187 confirmed
Resident #47 had complained of acute pain rated 8/10 to the nurse on 09/04/23 as well as notes that
resident could not lift his right or left leg. Unit Manager LPN #187 denied facility had any evidence of
resident power of attorney or physician being contacted for a change in condition.
Interview on 11/15/23 at 12:42 P.M., with LPN #159 revealed Resident #47 had complained of new onset
pain 8/10 and confirmed resident was typically mobile and would walk all over the unit. LPN #47 revealed
she did not remember any specific details, but confirmed she did remember that resident did not get out of
bed at any time during her shift on 09/04/23 due to pain. LPN #47 reported she had no memory of calling
the Physician or Residents power of attorney and reporting the change in condition/acute pain or injury.
Interview on 11/15/23 at 3:20 P.M., with Director of Nursing (DON) revealed she would have expected the
LPN to contact the physician and family/power of attorney if a resident was having a change in condition or
new onset pain.
Review of the policy titled Notification of Changes, dated 2022 revealed the facility shall promptly inform the
resident, physician, and resident representative when there was a change in condition. Circumstances
requiring a notification include an accident resulting in injury, potential to require physician intervention,
significant change in status and circumstances requiring an altered treatment including acute condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 10 of 53
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
11/16/2023
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)
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 policy review, the facility failed to ensure beneficiary notices were
completed. This affected two (#22 and #82) of four residents reviewed for beneficiary notices. The facility
census was 85.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 05/04/22, with diagnoses
including femur fracture, vascular leukoencephalopathy, Alzheimer's disease, diabetes, and dementia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively
impaired and required extensive assistance of one to two staff for mobility.
Review of the record revealed no evidence of a skilled nursing facility advanced beneficiary notification
(SNF ABN) on file when skilled services ended on 09/07/23.
2. Review of the medical record for Resident #82 revealed an admission date of 07/18/23, with diagnoses
including pleural effusion, Alzheimer's disease, dementia, weakness, and altered mental status.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively
impaired and required supervision assist with mobility.
Review of the record revealed no evidence of either a notice of Medicare non-coverage (NOMNC) or a
skilled nursing facility advanced beneficiary notification (SNF ABN) on file when skilled services ended on
10/01/23.
Interview on 11/15/23 at 4:21 P.M., with Regional MDS Nurse #305 revealed facility was unable to locate
the SNF ABN for Resident #22 and was unable to locate the NOMNC or SNF ABN for Resident #82.
Review of the policy titled, Advanced Beneficiary Notices dated 2023 revealed the facility would provide
timely notices regarding Medicare eligibility and coverage. Additional notices shall be issued for Medicare
Beneficiary including a NOMNC when Medicare covered services were ending and SNF ABN to inform of
cost of services not covered. The notices shall be placed into the residents file and retained for at least five
years.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 11 of 53
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
11/16/2023
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)
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of
medical record review, observation, staff interview, and policy review, the facility failed to ensure a
resident's personal privacy was honored. This affected one (#80) of two residents reviewed for personal
privacy. The facility census was 85.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #80 was admitted on [DATE], with diagnoses including
inclusion body myositis, essential primary hypertension, mixed hyperlipidemia, chronic tension, weakness,
and repeated falls.
Review of the Minimum Data Set (MDS) assessment, dated 10/26/23, revealed the resident was cognitively
intact. Resident #80 had functional limitation in range of motion on both sides and utilized a wheelchair.
Review of the care plan, dated 06/15/23, revealed Resident #80 required activities of daily living self-care
performance due to body myositis and required assistance by one staff with bathing/showering as
necessary and was dependent with transfers via Hoyer lift for two staff members.
Observation on 11/14/23 at 10:00 A.M., revealed the shower room door opened and Resident #80
observed completely nude sitting in a wheelchair inside the shower room facing the open door for
approximately eight to ten seconds before the door closed.
Observation on 11/14/23 at 10:04 A.M., revealed Resident #80 in a gown, sitting in a wheelchair being
escorted through the hall by State Tested Nursing Assistant (STNA) #169. Resident #80's feet were
propped on the foot petals and the gown did not cover past the resident's knees allowing for a visual of the
residents exposed and uncovered groin. In the hallway were numerous residents and staff.
Interview on 11/14/23 at 10:06 A.M., with STNA #169 verified Resident #80 was naked and fully exposed
when the shower room door was opened in addition to Resident #80 not being appropriately covered when
being assisted back to his room.
Review of policy titled, Resident Rights, dated 2023, verified the resident has a right to personal privacy
which includes personal care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 12 of 53
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
11/16/2023
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident interview and staff interviews, the facility failed to ensure a resident's bed linens
were changed when the linens became soiled and torn. This affected one (#47) of three residents reviewed
for linens. The facility census was 85.
Findings include
Review of the medical record for the Resident #47 revealed an admission date of 05/19/20, with diagnoses
including chronic obstructive pulmonary disease, heart failure, muscle weakness, depression and insomnia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had significant
cognitive impairment and required limited one person assist for transfers and extensive assist of one staff
for toileting and extensive assistance of two staff physical assist for personal hygiene.
Observation on 11/13/23 at 10:11 A.M., of Resident #47 revealed the resident was sleeping in his bed and
the bed sheets had numerous food stains from juice and likely coffee and what appeared to be urine stains.
The linens also were covered in crumbs and had two visible rips/holes about the size of quarters on the
door side of the mattress.
Observation and interview on 11/14/23 at 12:05 P.M., with Resident #47 revealed the stains and hole were
still present and resident's linens had not been changed since the previous observation on 11/13/23.
Resident #47 revealed he did not know facility had extra linens and had the resources to change his linens.
The sheet was observed and the resident had medical tape covering the holes in his linens. Observations
revealed the facility had a linen closet that contained clean linens for resident's bed.
Interview and observation on 11/14/23 at 12:23 P.M., with Maintenance Staff #138 revealed resident linens
were dirty with crumbs and stains and he confirmed the linens had holes. When asked Resident #47
reported he got tape from the nurse for the holes. Maintenance Staff #138 revealed the facility should be
changing his linens when soiled or ripped.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 13 of 53
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
11/16/2023
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)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, review of self-reported incidents (SRI), staff interview, and policy review,
the facility failed to thoroughly investigate an allegation of injury of unknown origin and abuse. This affected
one (#61) of three residents reviewed for abuse. The facility census was 85.
Residents Affected - Few
Findings include:
Review of the closed medical record for Resident #61 revealed an admission date of 09/15/23 and
discharged on 11/08/23. Diagnoses for Resident #61 included fracture of unspecified part of the neck of left
femur subsequent encounter for closed fracture with routine healing, vascular dementia severe,
hematemesis, epilepsy, anxiety disorder, and insomnia.
Review of the Minimum Data Set (MDS) assessment, dated 09/24/23, revealed the resident was severely
cognitively impaired and required extensive one person assistance with bed mobility, transfers, locomotion
on and off the unit, dressing, toilet use, and personal hygiene.
Review of the Self-Reported Incident (SRI), dated 11/03/23, revealed Resident #61 was discovered to have
an injury to the pelvic area with the aide and family at bedside. The injury of unknown origin was
immediately reported, and Resident #61 was sent to the hospital for an x-ray and assessment. Resident
#61's family then alleged an aide was rough with Resident #61 the previous day. The investigation was
found to be unsubstantiated.
Review of the facility's investigation, no date, revealed no common residents were interviewed or assessed.
There was no evidence of the potential witness of the roommate being interviewed.
Interview on 11/15/23 at 5:09 P.M., with the Administrator verified no common residents were interviewed or
assessed for allegations of injury of unknown origin or abuse, including Resident #61's roommate who was
cognitively intact.
Review of the policy titled, Abuse Neglect and Exploitation, dated 2023, verified written procedures for
investigations include identifying and interviewing all involved persons including the alleged victim, alleged
perpetrator, witnesses, and others who might have knowledge of the allegations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 14 of 53
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
11/16/2023
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)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and policy review, the facility failed to ensure the resident, or their
representative, received written transfer information. This affected one (#86) of one resident reviewed for
hospitalization. The facility census was 85.
Findings include:
Review of the closed medical record revealed Resident #86 was admitted on [DATE] with re-entry on
10/11/23 and discharged on 10/13/23. Diagnoses for Resident #86 included Huntington's disease,
depression, post-traumatic stress disorder, restless leg syndrome, and neuromuscular dysfunction of
bladder.
Review of the nursing progress note dated 10/13/23 revealed Resident #86 had pulled the catheter out fully
while the balloon to catheter was still inflated. Resident #86 was bleeding from the groin area. Emergency
services were contacted, and notification was provided to the physician and emergency contact. A further
record review revealed transfer information was not provided to the resident or the resident representative.
Interview on 11/16/23 at 10:49 A.M., with Business Office Manager #137 verified Resident #86 did not
receive a notice of transfer information due to the type of medical coverage he had.
Review of the policy titled, Transfer and Discharge, dated 2023, verified emergency transfers/discharges
are provided a notice of transfer and the facility's bed hold policy to the resident and representative as
indicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 15 of 53
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
11/16/2023
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)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and policy review, the facility failed to ensure bed hold information
was provided to resident upon hospitalization. This affected one (#86) of one resident reviewed for
hospitalization. The facility census was 85.
Findings include:
Review of the closed medical record revealed Resident #86 was admitted on [DATE] with re-entry on
10/11/23 and discharged on 10/13/23. Diagnoses for Resident #86 included Huntington's disease,
depression, post-traumatic stress disorder, restless leg syndrome, and neuromuscular dysfunction of
bladder.
Review of the nursing progress note dated 10/13/23, revealed Resident #86 had pulled the catheter out
fully while the balloon to catheter was still inflated. Resident #86 was bleeding from the groin area.
Emergency services were contacted, and notification was provided to the physician and emergency
contact. A further record review revealed transfer information was not provided to the resident or the
resident representative.
Interview on 11/16/23 at 10:49 A.M., with Business Office Manager #137 verified Resident #86 did not
receive bed hold information due to the type of medical coverage he had.
Review of the policy titled, Transfer and Discharge, dated 2023, verified emergency transfers/discharges
are provided a notice of transfer and the facility's bed hold policy to the resident and representative as
indicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 16 of 53
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
11/16/2023
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)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, and staff interview, the facility failed to ensure an accurate Minimum
Data Set Assessment (MDS) was completed. This affected one (#81) of 25 residents reviewed for accurate
MDS assessments. The facility census was 85.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #81 revealed an admission date of 09/01/23, with diagnoses
including hypertension, dementia, glaucoma, cataract, and insomnia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #81 was
cognitively impaired, had adequate hearing, speech was clear, and the resident was understood and
understands others, vision was moderately impaired. Review of the active diagnoses revealed no vision
diagnoses.
Review of the visual function care assessment areas (CAA) which triggered in the MDS secondary to the
inability to complete visual assessment secondary to cognitive loss, noted visual deficits related to
glaucoma, cataracts and macular degeneration with blindness noted in the right eye.
Review of the physician's progress note from the eye care group dated 11/14/23 revealed cataract, nuclear
in both eyes, glaucoma open angle with legal blindness in right eye.
Observation on 11/13/23 at 3:32 P.M., revealed Resident #81 was pacing in and out of the room into the
hallway and verbalizing to anyone which passed by the resident help me, I cannot see.
Interview on 11/14/23 at 1:54 P.M., with Licensed Practical Nurse (LPN) #112 verified Resident #81 is
extremely anxious about not being able to see.
Interview on 11/14/23 at 2:22 P.M., with LPN #157, the MDS Nurse, verified Resident #81 admission MDS
was inaccurate. LPN #157 further verified Resident #81 had vision diagnoses of glaucoma and cataracts
with visual deficits identified in the admission assessment were not correctly captured in the active
diagnoses portion of the comprehensive admission assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 17 of 53
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
11/16/2023
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)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to ensure an accurate and updated Pre-admission
Screening and Resident Review (PASARR) was completed. This affected one (#21) of two residents
reviewed for PASARR. The facility census was 85.
Findings include:
Review of the medical record for the Resident #21 revealed an admission date of 08/29/17, with diagnoses
including bilateral osteoarthritis of knee, muscle weakness, depression, anxiety, and unspecified psychosis.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had mild
cognitive impairment with a BIMS of 12. Residents mobility was not assessed in the MDS, but resident
required supervision with mobility.
Review of physician order dated 07/28/23 revealed an order for fluvoxamine maleate tablet for depression.
A physician order dated 09/08/23 revealed an order for trazadone oral tablet for depression. The physician
order dated 10/20/23 revealed an order for Cymbalta oral capsule for depression.
Review of the PASSAR dated 03/03/17 revealed the document was marked no in regard to mental
disorders.
Interview on 11/14/23 at 4:57 P.M., with Social Services #132 revealed Resident #21's PASARR completed
03/03/17 did not include any of his diagnosed mental disorders. Social Services also confirmed facility had
no evidence of an updated PASARR being completed since 03/03/17.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 18 of 53
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
11/16/2023
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, staff interview, record review and policy review, the facility failed to ensure
an oxygen care plan was developed for Resident #52 and a vision care plan was developed for Resident
#81. This affected two (#52 and #81) of 25 resident care plans reviewed. The facility census was 85.
Findings include
1. Review of the medical record for Resident #52 revealed an admission date of 08/02/23. Diagnoses
included complete traumatic amputation at knee level, vascular disease, diabetes and chronic viral hepatitis
c.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively
impaired and required extensive assistance of one to two staff members for mobility and activities of daily
living.
Review of the plan of care dated 10/26/23 revealed Resident #52 did not have any care plan category or
interventions for oxygen use.
Review of physician orders for 11/13/23 for Oxygen via nasal cannula at two liters per minute continuous.
Facility had no prior orders for resident oxygen.
Interview on 11/15/23 at 8:46 A.M., with Unit Manager Licensed Practical Nurse (LPN) #187 revealed
Resident #52 had no care plan for oxygen.
Review of policy titled Oxygen Administration dated 2023, revealed oxygen shall be administered to
residents who need it consistent with professional standards of practice, the comprehensive care plans and
resident goals and preferences. Oxygen shall be care planned and include type of oxygen, equipment
settings and monitoring of oxygen.
2. Review of the medical record for Resident #81 revealed an admission date of 09/01/23, with diagnoses
including hypertension, dementia, glaucoma, cataract, and insomnia.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #81 was cognitively
impaired, had adequate hearing, speech was clear, and the resident was understood and understood
others, vision was moderately impaired. Required the supervision of one person for bed mobility, dressing,
toilet use and personal hygiene. Resident #81 was Independent with walking, locomotion, eating, transfers
and Independent with showers.
Review of the visual function care assessment areas (CAA) which triggered in the MDS secondary to the
inability to complete visual assessment secondary to cognitive loss, noted visual deficits related to
glaucoma, cataracts and macular degeneration with blindness noted in the right eye.
Review of the baseline care plan dated 09/02/23 and review of the comprehensive care plan dated
09/06/23, with revisions on 09/08/23, 11/10/23 and 11/14/23 remained silent related to a plan of care for
Resident #81's vision.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 19 of 53
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
11/16/2023
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Review of the physicians progress note from the eye care group dated 11/14/23 revealed cataract, nuclear
in both eyes, glaucoma open angle with legal blindness in right eye.
Observation on 11/13/23 at 3:32 P.M., revealed Resident #81 paced in and out of room into the hallway and
verbalizing to anyone which passed by the resident help me, I cannot see.
Residents Affected - Few
Interview on 11/14/23 at 1:54 P.M., with Licensed Practical Nurse (LPN) #112 verified Resident #81 is
extremely anxious about not being able to see.
Interview on 11/14/23 at 2:16 P.M., with the Unit Manager, Registered Nurse (RN) #187 revealed the unit
manager is responsible for the base line care plan and further verified the vision needs for Resident #81
had not been identified in either the baseline care plan or the comprehensive care plan.
Interview on 11/14/23 at 2:22 P.M. with LPN #157, the MDS Nurse, visual acuity flagged on the admission
MDS for Resident #81 and had not been captured in the admission care plan.
Review of the updated policy titled Comprehensive Care Plans, stated the facility is to develop and
implement a comprehensive person-centered care plan for each resident that includes measurable
objectives and timeframe's to meet a residents medical, nursing, mental and psychosocial needs that are
identified in the comprehensive assessment, recognizing the residents strengths and needs. Additionally,
the policy stated a comprehensive care plan with be developed within seven days of the completed
comprehensive MDS assessment with all Care Assessment Areas triggered by the MDS will be considered
in the development of the care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 20 of 53
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
11/16/2023
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident and resident representative interview, staff interview, and facility policy, the
facility failed to ensure care plan conferences were offered timely. This affected four (#13, #22, #24, and
#47) of four residents reviewed for care plan conferences. The facility census was 85.
Findings include:
Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included
hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cytomegaloviral
disease, unspecified dementia without behavioral disturbance, atherosclerotic heart disease of native
coronary artery without angina pectoris, hypothyroidism, aphasia, major depressive disorder, essential
hypertension, and hyperlipidemia.
Review of the Minimum Data Set (MDS) assessment, dated 08/31/23, revealed the resident was cognitively
intact.
Review of care conference progress notes, dated since admission, revealed Resident #13 had care
conferences on 06/24/22, 09/29/22, 04/14/23, and 10/11/23.
Interview on 11/16/23 at approximately 4:00 P.M., with Social Services #132 verified Resident #13 did not
have quarterly care conferences completed timely adding this is an area the facility identified and has been
working on.
2. Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included
unspecified fracture of lower end of left femur subsequent encounter for closed fracture with routine
healing, progressive vascular leukoencephalopathy, Alzheimer's disease, type two diabetes mellitus with
unspecified complications, mixed hyperlipidemia, hypomagnesemia, dementia in other disease classified
elsewhere, pruritus, vitiligo, dermatitis, essential (primary) hypertension, and diverticulitis of intestine.
Review of the MDS assessment, dated 08/07/23, revealed the resident was cognitively impaired.
Interview on 11/13/23 at 2:29 P.M., with Resident #22's Resident Representative revealed quarterly care
conferences had not occurred.
Review of care conference progress notes, dated since admission, revealed Resident #22 had a care
conference on 05/12/22, 09/18/22, and 05/03/23.
Interview on 11/14/23 at 4:40 P.M., with Social Services #132 verified quarterly care conferences were not
completed timely for Resident #22.
3. Review of the medical record revealed Resident #24 was initially admitted on [DATE] with re-entry on
10/14/19. Diagnoses included unspecified dementia unspecified severity without behavioral disturbance
psychotic disturbance mood disturbance and anxiety, acute kidney failure, dysarthria, and anarthria,
essential (primary) hypertension, hyperlipidemia, major depressive disorder recurrent, major depressive
disorder severe with psychotic features.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 21 of 53
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
11/16/2023
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)
F 0657
Review of the MDS assessment, dated 08/11/23, revealed the resident is moderately cognitively impaired.
Level of Harm - Minimal harm
or potential for actual harm
Review of care conferences since June 2022, revealed Resident #24 had care conferences on 06/17/22,
09/09/22, 04/26/23, and 09/05/23.
Residents Affected - Some
Interview on 11/16/23 at approximately 4:00 P.M., with Social Services #132 verified Resident #24 did not
have quarterly care conferences completed timely adding this is an area the facility identified and has been
working on.
4. Review of the medical record for Resident #47 revealed an admission date of 05/19/20. Diagnoses
included chronic obstructive pulmonary disease, heart failure, muscle weakness, depression, and insomnia.
Review of progress notes dated from 07/2021 to 11/16/23 revealed care conferences were held on
08/02/21, 03/01/22, 06/03/22, 08/19/22, 04/18/23, 09/05/23. Chart review revealed no evidence of Care
conferences being held fourth quarter for 2021, fourth quarter of 2022, and first quarter of 2023.
Additionally Resident went about five months between care conferences from 04/2023 to 09/2023.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had significant
cognitive impairment with a BIMS of 4 and required limited one person assist for transfers and mobility.
Interview on 11/13/23 at 4:08 P.M., with Resident #47's representative revealed staff to not invite her to
care conferences.
Interview on 11/14/23 at 11:30 A.M., with Social Services #132 revealed when she started at the facility,
they noticed Residents had not been receiving care conferences. She revealed care conferences should be
held quarterly/every three months and confirmed facility did not have evidence of these being done since
the last annual survey.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 22 of 53
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
11/16/2023
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)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
Observation on 11/14/23 at 8:06 A.M., noted Registered Nurse (RN) #190 obtain Resident #78 medications
from the medication cart. One medication included a Breo Ellipta (fluticasone furoate and vilanterol
inhalation powder) 100-25 microgram inhaler. RN #190 handed Resident #78 the inhaler and the resident
took one inhalation. No prompts or directions were given for Resident #78 to rinse his mouth and discard
(spite out) the contents.
Residents Affected - Few
On 11/14/23 at 8:10 A.M., interview with RN #190 was unaware the resident is required to rinse their mouth
with water and spit out the contents.
Review of Resident #78's medical record noted on 06/15/23 a physician order was initiated for the
administration of Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone
Furoate-Vilanterol) one puff inhaled orally one time a day for chronic obstructive pulmonary disease.
Review of the manufacturer's instructions revealed Breo Ellipta (fluticasone furoate and vilanterol inhalation
powder) 100-25 microgram (MCG) inhaler revised May 2023 revealed the inhaler can cause serious side
effects, including: fungal infection in mouth or throat (thrush). Rinse mouth with water without swallowing
after using Breo Ellipta to help reduce chance of getting thrush.
Review of the policy titled, Medication Administration revised February 2023, medications are to be
administered as ordered in accordance with manufacturer specifications.
Interview with the Director of Nursing on 11/14/23 at 1:15 P.M. during review Breo Ellipta inhaler
manufacturer instruction confirmed following administration the resident is to rinse their mouth with water
and discard the contents. Additional review of facility Medication Administration policy at the time of
interview confirmed medications are to be administered as ordered in accordance with manufacturer
specifications.
Based on medical record review, staff interview, manufacturer's instruction review, and facility policy, the
facility failed to ensure nursing staff worked within their scope of practice. This affected two (#288 and #78)
of five resident reviewed for medication administration. The facility census was 85.
Findings include:
Review of the medical record revealed Resident #288 was admitted on [DATE]. Diagnoses included
acidosis, arteriovenous fistula, unspecified cirrhosis of liver, anemia, chronic kidney disease,
hyperlipidemia, type two diabetes mellitus, and essential primary hypertension.
Review of the Minimum Data Set (MDS) assessment, dated 11/4/23, revealed the entry assessment had
been completed.
Review of physician orders, dated 11/05/23, revealed an order for Resident #288 to receive Humalog
Kwickpen subcutaneous solution pen-injector 100 unit/milliliter (ml) with instructions to inject as per sliding
scale: if 151-200 provide 2 units, if 201-250 provide 4 units, if 251-300 provide 6 units, if 301-350 provide 8
units, and if 351-400 provide ten units subcutaneously before meals and at
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 23 of 53
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
11/16/2023
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)
F 0658
Level of Harm - Minimal harm
or potential for actual harm
bedtime for diabetes mellitus. The order did not provide instructions for blood sugars over 400 when not at
meals or bedtime.
Review of blood sugar levels, dated 11/08/23 at 4:34 P.M., revealed Resident #288 had a blood sugar level
of 468 milligrams per deciliter (mg/dl).
Residents Affected - Few
Review of nursing progress notes, dated 11/08/23 at 4:36 P.M., revealed Resident #288 had a blood sugar
of 468 mg/dl and a message was left with the on-call service.
Review of nursing progress note, dated 11/08/23 at 6:45 P.M., revealed another call was made to the
physician regarding elevated blood sugar of 468 mg/dl and a message was left.
Review of nursing progress note, dated 11/12/23 at 10:52 A.M., revealed a message was left with the
physician's on call service regarding Resident #288's blood sugar of 479 mg/dl. The note reported Resident
#288 received his long acting (insulin) as well and will recheck in an hour. Facility waiting for a call back
from the physician on further instructions and a note was left for the physician/nurse practitioner regarding
the residents constant high blood sugar levels.
Review of blood sugar levels, dated 11/12/23 at 4:25 P.M., revealed Resident #288's blood sugar level was
594 mg/dl.
Review of nursing progress note, dated 11/12/23 at 4:25 P.M., revealed a message was left with the
physician on call service again regarding elevated blood sugar with the blood sugar level current 594 mg/dl.
Ten units of insulin was administered.
Interview on 11/15/23 at 9:00 A.M., with Licensed Practical Nurse (LPN) #175 verified the physician order
did not provided instructions when Resident #288's blood sugar was over 400 mg/dl and when she did not
receive a call back, she administered 10 units of insulin.
Review of the policy titled, Administration of Insulin, dated 2023, verified all insulin will be administered in
accordance with physician's orders.
Review of the policy titled, Provision of Quality of Care, dated 2023, verified based on comprehensive
assessments, the facility will ensure residents receive treatment and care by qualified persons in
accordance with professional standards of practice, the comprehensive person-centered care plans, and
the residents' choices.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 24 of 53
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
11/16/2023
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)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record for Resident #52 revealed an admission date of 08/02/23. Diagnoses included complete
traumatic amputation at knee level, vascular disease, diabetes, and chronic viral hepatitis c.
Residents Affected - Few
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively
impaired and required extensive assistance of one to two staff members for mobility and activities of daily
living.
Review of the plan of care dated 10/26/23 revealed Resident #52 had an ADL self-care deficit related to
amputation with interventions for one to two staff to assist with bathing and provide a bed bath if not able to
shower.
Review of the shower sheets revealed dated 09/01/23 to 11/13/23 revealed resident last had his hair
washed on 10/12/23. Resident #52 was noted to not need nails trimmed on 11/13/23 according to the
shower sheets. Shower sheets made no mention of residents' nails being cleaned or trimmed during this
period of time.
Interview and observation on 11/13/23 at 10:28 A.M., with Resident #52 revealed staff have not washed his
hair, trimmed his beard, or trimmed his nails in a long time. Resident #52's hair appeared matted and was
stick in a fattened stingy shape from laying on his pillow. Resident #52's nails were dirty with a brownish
material under the nails, the nails were long with some nails ¼ to ½ inch of growth past the
nail bed. Resident #52 also had a shaggy beard several inches in length. Resident #52 revealed he had
asked to have his beard trimmed and preferred it to be more a scruff and very short than a long stringy
beard.
Interview and observation on 11/14/23 at 9:55 A.M., with Resident #52 and Licensed Practical Nurse (LPN)
#126 revealed beard hair and nails continued in poor condition from the previous day. LPN #126 confirmed
Resident #52's hair was greasy and stuck in position from the pillow and his nails were long, jagged, and
dirty. LPN #126 revealed she would have a State Tested Nurse Aide (STNA) provide ADL care. Resident
#52 informed LPN #126 he was agreeable to care.
Interview and observation on 11/15/23 at 8:21 A.M., with Resident #52 and STNA #181 revealed staff did
not return to provide care on 11/14/23. Resident #52's hair was still greasy and stuck in the same position
as before, beard was shaggy and unkempt and residents nails were jagged and long and dirty. STNA #181
confirmed observations and revealed she would offer resident to get cleaned up and Resident was
agreeable to this.
Review of the policy titled, Activity of Daily Living (ADLs), dated 2022, revealed facility would provide care
and services including bathing dressing and grooming.
This deficiency is a recite from the complaint survey dated 10/10/23.
Based on observation, medical record review, resident interview, staff interview and policy review, the
facility failed to ensure dependent residents were provided with effective grooming and hygiene. This
affected two (#33, #52) of 24 residents observed for the provision of activities of daily living. The facility
census was 85.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 25 of 53
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
11/16/2023
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)
F 0677
Findings include:
Level of Harm - Minimal harm
or potential for actual harm
1. Review of Resident #33's medical record revealed an admission date of 06/05/23, with the diagnoses
including: cerebral infarction, congestive heart failure, and hypertension. According to the minimum data set
assessment dated [DATE] assessed Resident #33 with severe cognitive impairment, sometimes
understands or is understood, moderately impaired vision without corrective lenses, hearing deficit,
required partial to moderate staff assistance to complete hygiene task and activities of daily living.
Residents Affected - Few
Review of the nursing plan of care dated 08/09/23 to address Resident #33 activities of daily living self-care
deficit related to amputation of right arm. Interventions included resident requires the assistance of one
staff with hygiene.
Observations on 11/14/23 at 9:50 A.M., 10:35 A.M., 1:37 P.M. and on 11/15/23 at 9:27 A.M., noted
Resident #33 with long facial hair, lacking grooming.
Interview on 11/14/23 at 10:35 A.M., with Resident #33, during observation, revealed the resident prefers to
be clean shaven. Resident #33 requested to be shaved due to the lack of ability to be able to complete
himself. However, he has not received a shave for an undetermined amount of time.
Review of medical record task completion lacked documentation indicating Resident #33 was provided with
assistance shaving.
Interview on 11/14/23 at 10:54 A.M., with State Tested Nurse Aide (STNA) #191 confirmed Resident #33
with heavy beard growth and required assistance with activities of daily living. STNA #191 stated they were
unaware Resident #191 preferred to be clean shaven.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 26 of 53
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
11/16/2023
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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, resident and staff interview, physician interview, and policy reviews, the facility failed
to ensure clear physician instructions for blood sugars above or below parameters, physician and nursing
staff had no barriers to communication, and a resident with a change in condition was treated and
monitored appropriately. This affected one (#288) of one residents reviewed for insulin. In addition, the
facility failed to properly assess and monitor change in condition for Resident #47 related to acute pain. The
facility census was 85.
Residents Affected - Few
Findings include:
1. Review of the medical record revealed Resident #288 was admitted on [DATE]. Diagnoses included
acidosis, arteriovenous fistula, unspecified cirrhosis of liver, anemia, chronic kidney disease,
hyperlipidemia, type two diabetes mellitus, and essential primary hypertension.
Review of the Minimum Data Set (MDS) assessment, dated 11/04/23, revealed the entry assessment had
been completed.
Review of physician orders, dated 11/05/23, revealed an order for Resident #288 to receive Humalog
Kwickpen subcutaneous solution pen-injector 100 unit/milliliter (ml) with instructions to inject as per sliding
scale: if 151-200 provide 2 units, if 201-250 provide 4 units, if 251-300 provide 6 units, if 301-350 provide 8
units, and if 351-400 provide ten units subcutaneously before meals and at bedtime for diabetes mellitus.
The order did not provide instructions for blood sugars over 400 when not at meals or bedtime.
Review of blood sugar levels, dated 11/08/23 at 4:34 P.M., revealed Resident #288 had a blood sugar level
of 468 milligrams per deciliter (mg/dl).
Review of nursing progress notes, dated 11/08/23 at 4:36 P.M., revealed Resident #288 had a blood sugar
of 468 mg/dl and a message was left with the on-call service.
Review of nursing progress note, dated 11/08/23 at 6:45 P.M., revealed another call was made to the
physician regarding elevated blood sugar of 468 mg/dl and a message was left.
Review of nursing progress note, dated 11/12/23 at 10:52 A.M., revealed a message was left with the
physician's on call service regarding Resident #288's blood sugar of 479 mg/dl. The note reported Resident
#288 received his long acting (insulin) as well and will recheck in an hour. Facility waiting for a call back
from the physician on further instructions and a note was left for the physician/nurse practitioner regarding
the residents constant high blood sugar levels.
Review of blood sugar levels, dated 11/12/23 at 4:25 P.M., revealed Resident #288's blood sugar level was
594 mg/dl.
Review of nursing progress note, dated 11/12/23 at 4:25 P.M., revealed a message was left with the
physician on call service again regarding elevated blood sugar with the blood sugar level current 594 mg/dl.
Ten units of insulin were administered. Resident #288's spouse reported the resident had ensure, coffee,
and juices throughout the day. Resident #288 was asymptomatic.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 27 of 53
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
11/16/2023
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 11/15/23 at 9:00 A.M., with Licensed Practical Nurse (LPN) #175 verified the physician order
did not provided instructions when Resident #288's blood sugar was over 400 mg/dl. LPN #175 stated
when she was unable to connect with the physician she administered 10 units of insulin. LPN #175 verified
on 11/08/23 and 11/12/23 Resident #288's blood sugar was not rechecked for approximately five hours.
Interview on 11/15/23 at 3:38 P.M., with Doctor in Medicine (MD) #500 revealed he had tried to return the
nurse's call but could not get through the facility phones. When asked specifically, MD #500 reported he
would have recommended a blood sugar recheck be completed no later than four hours later.
Review of the policy titled, Administration of Insulin, dated 2023, verified all insulin will be administered in
accordance with physician's orders.
Review of the policy titled, Provision of Quality of Care, dated 2023, verified based on comprehensive
assessments, the facility will ensure residents receive treatment and care by qualified persons in
accordance with professional standards of practice, the comprehensive person-centered care plans, and
the residents' choices.
Review of the policy titled, Notification of Changes, dated 2022, verified circumstances requiring notification
significant change in resident's condition which may include clinical complications or circumstances that
require a need to alter treatment.
2. Review of the medical record for Resident #47 revealed an admission date of 05/19/20. Diagnoses
included chronic obstructive pulmonary disease, heart failure, muscle weakness, depression, and insomnia.
Review of the Medication Administration Record (MAR) dated August 2023 revealed residents pain had
been monitored twice daily. Resident reported pain at 2/10 on one of 62 assessments, 3/10 on four of 62
assessments and all other assessments were zero of 10 with one marked as not applicable. The MAR also
reported Resident received one dose of Tylenol this month on 08/07/23 at 5:24P.M.
Review of the progress notes dated 09/04/23 at 8:25 A.M. revealed resident complained of pain to the right
leg. Resident was unable to lift the right leg upon being assessed the resident could not lift the left leg.
Resident stated I felt it a few days ago and it hurts 8/10 pain scale. Review of progress note dated 09/05/23
at 2:30 P.M., revealed STNA had found resident on the floor near the bathroom door with cane. Resident
stated he was trying to get to the bathroom. The resident was assessed, and vitals were within normal limits
and the resident complained of pain of the right leg and right hip. Resident was sent to the hospital for
evaluation. Progress note dated 09/05/23 at 7:51 P.M. revealed the hospital informed staff resident was
being admitted with diagnosis of right hip fracture.
Review of the Medication Administration Record (MAR) dated September 2023 revealed residents pain had
been monitored two to three times daily. On 09/2023, Resident complained of pain 5/10 on 09/03/23 and
09/04/23 and 09/05/23. The MAR also reported Resident received one dose of Tylenol 09/03/23 at 3:14P.M.
and one dose on 09/05/23 at 10:49 A.M.
Review of the fall investigation dated 09/05/23 revealed a fall occurred 09/05/23 in residents room outside
the bathroom. The investigation found a rug in front of the sink outside the bathroom to be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 28 of 53
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
11/16/2023
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)
F 0684
a possible cause.
Level of Harm - Minimal harm
or potential for actual harm
Review of the History and Physical from the hospital dated 09/05/23 revealed x-ray results from a x ray of
right femur revealed a displaced fracture of trochanter.
Residents Affected - Few
Review of hospital orthopedic consult note dated 09/05/23 revealed the hospital plan to treat
non-operatively, with pain management and Physical and Occupational therapy evaluation.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had significant
cognitive impairment with a BIMS of 4 and required limited one person assist for transfers and extensive
assist of one staff for toileting and extensive assistance of two staff physical assist for personal hygiene.
Review of physician orders for 10/07/20 revealed an order for Tylenol tablet (acetaminophen) with
instructions to given one tablet (650 milligram) by mouth every 6 hours as needed for pain.
Review of the plan of care dated 10/26/23 revealed Resident #47 had an actual fall related to balance and
unsteady gait with interventions to ensure floors were free of clutter. The care plan revealed resident was
on pain medication related to generalized pain with interventions to administer medications as ordered by
physician and monitor/document side effects and effectiveness and monitor for increased risk of falls. The
care plan had a second section related to pain with additional interventions to anticipate residents need for
pain relief and respond immediately to any complaint of pain and identify and record previous pain history
and management of that pain and impact on function and identify previous response to pain relief.
Interview on 11/15/23 at 8:46 A.M., with Unit Manager LPN #187 confirmed Resident #47 had complained
of acute pain rated 8/10 to the nurse on 09/04/23. She also noted that a resident could not lift his right or
left leg. Unit Manager LPN denied facility had any evidence of resident being assessed properly for possible
injury and reported facility had any evidence of Resident having an x-ray ordered.
Interview on 11/15/23 at 12:42 P.M., with LPN #159 revealed Resident #47 had complained of new onset
pain 8/10 and confirmed resident was typically mobile and would walk all over the unit. LPN revealed she
did not remember any specific details, but confirmed she did remember that resident did not get out of bed
at any time during her shift on 09/04/23 due to pain.
Interview on 11/15/23 at 12:47 P.M., with LPN #208 revealed she had not been told any details of resident
being injured or assessed to have possible injuries until resident had a fall on 09/05/23.
Interview on 11/15/23 at 3:20 P.M., with DON revealed she would have expected the LPN to contact the
physician and regarding a change in condition or new onset pain, assess for injuries and offer pain
medication as ordered and document that these steps had been taken. DON confirmed facility had no
evidence staff treated his acute pain timely as resident reported 8/10 pain at 8:25 A.M. and was not given
any pain medication until the next day.
Review of the policy titled Provision of Quality Care, dated 2023 revealed the facility shall ensure residents
receive treatment and care by qualified persons and in accordance with professional standards of practice.
Each resident shall be provided care and services to attain or maintain the highest level of well-being.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 29 of 53
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
11/16/2023
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record, observation, staff interview and facility policy the facility failed to ensure fall
interventions were in place. This affected one (#22) of three residents reviewed for falls. The facility census
was 85.
Findings include:
Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included
unspecified fracture of lower end of left femur subsequent encounter for closed fracture with routine
healing, progressive vascular leukoencephalopathy, Alzheimer's disease, type two diabetes mellitus with
unspecified complications, mixed hyperlipidemia, hypomagnesemia, dementia in other disease classified
elsewhere, pruritus, vitiligo, dermatitis, essential (primary) hypertension, and diverticulitis of intestine.
Review of the Minimum Data Set (MDS) assessment, dated 08/07/23, revealed the resident was severely
cognitively impaired and required extensive one person assistance for transfers and locomotion on and off
the unit, required extensive two person assistance for bed mobility, dressing, toilet use, and personal
hygiene, and total dependence for walking in the room and corridor.
Review of fall documentation, dated 07/07/23, revealed Resident #22 had a fall with major injury and was
found on the floor next to the bed.
Review of the care plan, dated 06/06/22 and updated 07/07/23, revealed Resident #22 was at risk for falls
due to confusion and lack of awareness of safety needs. Interventions were numerous and included to have
the bed in the lowest position while in bed.
Observation on 11/14/23 at 8:10 A.M. revealed Resident #22 was in the resident bed and the bed was in a
high position with facility staff talking to the resident sitting in a chair next to the bed.
Observation on 11/14/23 at 9:50 A.M., 12:03 P.M., 2:30 P.M., and 4:40 P.M. revealed Resident #22 in bed,
alone in the room with the bed in a high position.
Interview on 11/14/23 at 4:40 P.M. with State Tested Nursing Assistant (STNA) #162 and an unidentified
STNA verified Resident #22's bed was in a high position. Facility staff verified Resident #22's roommates
bed was in the lowest position which was much lower than Resident #22's bed. Staff commented they were
not aware Resident #22's bed should still be in a low position.
Review of policy, Accidents and Supervision, dated 2023, verified using specific interventions to try to
reduce a resident's risks from hazards in the environment includes communicating the interventions to all
relevant staff, ensured interventions were put into action, ensured interventions are implemented correctly
and consistently.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 30 of 53
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
11/16/2023
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and policy review, the facility failed to ensure an
indwelling urinary catheter was appropriately secured and maintained to prevent infections. This affected
one (#77) of one resident reviewed for indwelling catheter maintenance and care. Facility census 85.
Findings include:
Review of the medical record revealed Resident #77 had an admission date of 04/26/23. Diagnoses
included type two diabetes mellitus, chronic kidney disease stage three, obstructive and reflux uropathy,
atrial fibrillation and dementia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had
impaired cognition. The resident required supervision for toileting hygiene. The resident was noted with an
indwelling urinary catheter.
Review of the physician orders dated 11/13/23 revealed the resident had an order for an indwelling urinary
catheter.
Observation on 11/13/23 at 9:34 A.M., revealed Resident #77's catheter drainage bag was resting directly
on the floor.
Interview on 11/13/23 at 9:38 A.M., Licensed Practical Nurse (LPN) #114 verified the catheter drainage bag
was on the floor and should not have been.
Review of the policy titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infections dated
06/06/19, revealed to not rest the catheter drainage bag on the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 31 of 53
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
11/16/2023
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and review of policy, the facility failed to ensure physician ordered weights
were obtained and accurate, and failed to ensure significant changes in weight were evaluated and
addressed. This affected one (#63) of two residents reviewed for nutritional status. The facility census was
85.
Residents Affected - Few
Findings include:
Review of Resident #63's medical record revealed an admission date of 06/16/23. Diagnoses included type
II diabetes mellitus, encephalopathy, heart disease, hypothyroidism, hypertension, and major depressive
disorder.
Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was
cognitively intact and required supervision for eating.
Review of the care plan dated 06/22/23 revealed Resident #63 had a nutritional problem or a potential for
nutritional problems related to diabetes mellitus, depression, variable weight fluctuations and variable meal
intake. Interventions included observing, recording, and reporting any signs or symptoms of malnutrition,
providing diet as ordered, and monitoring intake.
Review of the current orders for Resident #63 revealed an admission order written 06/16/23 for monthly
weights. Further review of the physician orders revealed an order written on 09/28/23 for a complex
carbohydrate high oil diet with regular texture, thin liquid and no pork and an order for weekly weights. An
order written on 10/31/23 to have staff provide redirection with food and offer high protein, low sugar items.
An order written on 11/06/23 indicated a diagnosis of morbid obesity needed to be added for Resident #63.
Review of the hospital discharge paperwork dated 06/16/23 revealed a discharge weight of 150 pounds.
Review of the admission weight for Resident #63 obtained on 06/17/23 at 8:30 A.M. revealed a weight of
150 pounds. Additional weights obtained on 07/01/23 at 4:45 P.M. revealed a weight of 151 pounds; on
07/03/22 at 2:11 P.M. a weight of 152.2; on 08/04/23 at 4:34 P.M. a weight of 184.2 pounds; 09/01/23 at
3:12 P.M. a weight of 194 pounds; and weights on 10/02/23 at 4:10 P.M. and on 11/06/23 at 9:06 A.M. at
262.2 pounds.
Review of the progress notes remained silent for communication related to Resident #63's weight gain and
remained silent for nutrition progress notes.
Review of the Nurse Practitioner visit notes from 06/17/23 to 11/15/23 and review of the physician visit note
dated 10/16/23 indicated the weight for Resident #63, however, no evaluation or assessment of the weight
gain was identified or ordered.
Interview on 11/14/23 at 2:09 P.M., with the Unit Manager, Registered Nurse (RN) #190 stated the nursing
assistants obtain weights and report them to the nurses, and any significant weight gains or losses are to
reported to the physician and to the dietician. RN #190 verified the record shows Resident #63 has had a
110-pound weight gain since admission (five months ago) and no evaluation of the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 32 of 53
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
11/16/2023
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)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
weight gain has occurred with either the physician or the dietician and further verified the weekly weights
were not obtained as ordered.
Review of a weight obtained on 11/14/23 at 3:02 P.M., revealed a weight of 190.6 pounds for Resident #63.
Review of the undated policy titled Weight Monitoring, revealed significant unintended changes in weight,
loss, or gain, may indicate a nutritional problem and the requires the physician to be notified and the
dietician to be consulted to assist with interventions. All actions are to be documented in the residents
medical record under nutrition progress notes.
Event ID:
Facility ID:
365898
If continuation sheet
Page 33 of 53
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
11/16/2023
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, staff interviews, record review and policy review, the facility failed to ensure
oxygen had an active order, the tubing had been changed timely, and had proper humidification of oxygen.
This affected two (#52 and #14) of three residents reviewed for respiratory care. The facility census was 85.
Residents Affected - Few
Findings included:
1. Review of the medical record for the Resident #52 revealed an admission date of 08/02/23. Diagnoses
included complete traumatic amputation at knee level, vascular disease, diabetes, and chronic viral
hepatitis c.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively
impaired with a BIMS of 9 and required extensive assistance of one to two staff members for mobility and
activities of daily living.
Review of the plan of care dated 10/26/23 revealed Resident #52 did not have any care plan category or
interventions for oxygen use.
Review of physician orders for 11/13/23 for Oxygen via nasal cannula at two liters per minute continuous.
The facility had no prior orders for resident oxygen.
Interview and observation on 11/13/23 at 10:36 A.M., with Resident #52 revealed Resident was lying in bed
and had oxygen via nasal cannula with the tubing properly in place. Resident #52 revealed his machine
typically had a green light on it and revealed he had requested the tubing to be replaced several days prior
without response from staff. The oxygen machine did not appear to be working properly and appeared to be
turned off. The tubing also had a replacement date of 11/02/23.
Interview and observation on 11/13/23 at 10:38 A.M., with Licensed Practical Nurse (LPN) #151 confirmed
Residents oxygen was turned off and when LPN #151 turned on the oxygen machine, Resident's oxygen
was set for three liters. LPN #151 also confirmed the tubing was dated for 11/02/23 and confirmed tubing
should be changed weekly. LPN #151 revealed staff likely turned the oxygen off when getting him up earlier
and forgot to turn it back on.
Interview on 11/15/23 at 8:46 A.M., with Unit Manager LPN #187 revealed she had entered an order for
oxygen on 11/13/23 after surveyor intervention. She confirmed no care plan was made for oxygen and
residents had no prior orders related to oxygen use.
2. Review of the medical record for Resident # 14 revealed an admission date of 05/13/20, diagnoses
included congestive heart failure and chronic respiratory failure.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively
impaired and required continuous oxygen therapy.
Review of the care plan for Resident #14 revealed altered respiratory status with difficulty breathing related
to anxiety, acute respiratory failure, and recent history of COVID.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 34 of 53
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
11/16/2023
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the current physician orders revealed Resident #14 revealed the head of the bed was to be
elevated to assist with shortness of breath, oxygen at two to three liters per nasal cannula at all times,
change all oxygen tubing and components and nebulizer and components every Thursday night with each
component dated.
Observation on 11/13/23 at 11:29 A.M., revealed Resident #14 had oxygen in place at three liters per
minute per nasal cannula infusing with the oxygen tubing dated 11/13/23. The humidification bottle
connected to the concentrator for which the nasal cannula was attached was dry, bulging and without a
date.
Interview with Resident #14, at the time of the observation, revealed the resident had inquired if the
humidification bottle was empty with the staff and no one had been back in to answer the question.
Interview on 11/13/23 at 11:49 A.M., with Licensed Practical Nurse (LPN) #114 verified the humidification
bottle on Resident #14's oxygen was empty and the bottle was bulging.
Review of the policy titled, Oxygen Administration dated 2023, revealed oxygen shall be administered to
residents who need it consistent with professional standards of practice, the comprehensive care plans and
resident goals and preferences. Oxygen shall be ordered by a physician, the care plan shall include type of
oxygen, equipment settings and monitoring of oxygen. Oxygen tubing shall be changed weekly and as
needed if soiled or contaminated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 35 of 53
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
11/16/2023
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)
F 0710
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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, physician interview and policy review, the facility failed to ensure
residents care was supervised by a physician when the physician was unable to have effective
communication with the nursing staff to provide direct orders for residents. This affected two (#9 and #288)
of two residents for a change in condition. The facility census was 85.
Residents Affected - Few
Findings include:
1. Review of the medical record revealed Resident #288 was admitted on [DATE]. Diagnoses included
acidosis, arteriovenous fistula, unspecified cirrhosis of liver, anemia, chronic kidney disease,
hyperlipidemia, type two diabetes mellitus, and essential primary hypertension.
Review of the Minimum Data Set (MDS) assessment, dated 11/4/23, revealed the entry assessment had
been completed.
Review of physician orders, dated 11/05/23, revealed an order for Resident #288 to receive Humalog
Kwickpen subcutaneous solution pen-injector 100 unit/milliliter (ml) with instructions to inject as per sliding
scale: if 151-200 provide 2 units, if 201-250 provide 4 units, if 251-300 provide 6 units, if 301-350 provide 8
units, and if 351-400 provide ten units subcutaneously before meals and at bedtime for diabetes mellitus.
The order did not provide instructions for blood sugars over 400 milligrams per deciliter (mg/dl).
Review of blood sugar levels, dated 11/08/23 at 4:34 P.M., revealed Resident #288 had a blood sugar level
of 468 mg/dl.
Review of nursing progress notes dated 11/08/23 at 4:36 P.M., revealed Resident #288 had a blood sugar
of 468 mg/dl, and a message was left with the on-call service.
Review of nursing progress note dated 11/08/23 at 6:45 P.M., revealed another call was made to the
physician regarding elevated blood sugar of 468 mg/dl and a message was left.
Review of blood sugar levels dated 11/12/23 at 10:54 A.M., revealed Resident #288's blood sugar was 479
mg/dl.
Review of nursing progress note dated 11/12/23 at 10:52 A.M., revealed a message was left with the
physician's on call-service regarding Resident #288's blood sugar of 479 mg/dl. Facility waiting for a call
back from the physician on further instructions and a note was left for the physician/nurse practitioner
regarding the resident's constant high blood sugar levels.
Review of blood sugar levels, dated 11/12/23 at 4:52 P.M., revealed Resident #288's blood sugar level was
594 mg/dl.
Review of nursing progress note, dated 11/12/23 at 4:25 P.M., revealed a message was left with the
physician on call service again regarding elevated blood sugar with the blood sugar level current 594 mg/dl.
Interview on 11/15/23 at 9:00 A.M., with Licensed Practical Nurse (LPN) #175 reported the physician
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 36 of 53
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
11/16/2023
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)
F 0710
had not called back regarding Resident #288's high blood sugar levels.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 11/15/23 at 9:17 A.M., with the Director of Nursing (DON) verified there was no documentation
of the physician returning the call related to Resident #288's high blood sugars on 11/08/23 and 11/12/23
and stated communicating with the physician was an ongoing concern. Subsequent interview with the
Administrator revealed the facility had identified connecting facility staff and physician had been a concern
since approximately the month of July and implemented a cordless phone. In addition, the facility had
purchased disposable phones, but the nurse's had not been trained and are not yet in use.
Residents Affected - Few
Interview on 11/15/23 at 3:38 P.M., with Doctor in Medicine (MD) #500 revealed he had tried to return the
nurse's call regarding Resident #288 but could not get through the facility phones timely.
Review of policy titled, Notification of Changes, dated 2022, verified circumstances requiring notification
significant change in resident's condition which may include clinical complications or circumstances that
require a need to alter treatment.
2. Review of the medical record for Resident #9 revealed an admission date of 01/01/23, diagnoses
included chronic obstructive pulmonary disease, hypertension, type II diabetes mellitus, peripheral
autonomic neuropathy, depression, and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) dated revealed Resident #9 was cognitively intact and
had episodes of refusing care.
Review of the progress notes dated 11/04/23 revealed Resident #9 refused the noon medications.
Registered Nurse (RN) #190 placed a call to the residents physician at 1:00 P.M. to notify the physician of
Resident #9's refusal of the noon medications. A second attempt to contact the physician was made on
11/04/23 at 2:08 P.M. with additional attempts to notify the physician of the resident's noon medication
refusal made at 3:18 P.M., 6:08 P.M. No return call was received.
Interview on 11/14/23 at 12:30 P.M., with RN #190 verified there are ongoing difficulties when attempting to
contact the physician. RN #190 stated the physician does not return pages.
Interview on 11/14/23 at 4:30 P.M. and again on 11/16/23 at 10:45 A.M., with the Director of Nursing
verified the house physician does not return calls and pages and further added it is a known issue.
Review of the undated policy titled Provision of Quality Care, stated the facility will ensure residents receive
treatment and care by qualified persons in accordance with professional standards of practice with each
resident receiving care and services to maintain the highest practicable physical, mental, and psycho-social
wellbeing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 37 of 53
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
11/16/2023
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)
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 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
(#39, #63 and #64) of 25 residents reviewed for physician services. The facility census was 85.
Residents Affected - Few
Findings include:
1. Review of Resident #39's medical record revealed an admission date of 08/07/23. Diagnoses included
cerebral infarction, type II diabetes mellitus, acute respiratory failure with hypoxia, hypertension, chronic
kidney disease, bell's palsy, and hemiplegia to the left, nondominant side.
Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had
moderate cognitive impairment.
Review of Resident #39's Physician Visit notes revealed Resident #39 was seen by the Nurse Practitioner
on 09/01/23, 10/11/23, 10/12/23, 10/13/23, 10/30/23, 11/07/23 and 11/13/23. No visits from the physician
were found.
There was no evidence in Resident #39's medical record that Resident #39 was evaluated by a physician
during the resident's stay at the facility from 08/07/23 to 11/16/23.
Interview on 11/16/23 at 10:45 A.M., with the Director of Nursing (DON) verified Resident #39 had only
seen by the Certified Nurse Practitioner and not the physician since 08/07/23 when Resident #39 admitted
to the facility.
2. Review of Resident #63's medical record revealed an admission date of 06/16/23. Diagnoses included
type II diabetes mellitus, encephalopathy, heart disease, hypothyroidism, hypertension, and major
depressive disorder.
Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was
cognitively intact.
Review of Resident #63's Physician Visit notes revealed Resident #63 was first seen by the physician on
10/06/23. The Nurse Practitioner first saw Resident #63 on 06/19/23 and at least monthly thereafter.
There was no evidence in Resident #39's medical record that Resident #39 was evaluated by a physician
during the first thirty days of admission.
Interview on 11/14/23 at 4:30 P.M., with the Director of Nursing (DON) verified Resident #63 had only seen
by the Certified Nurse Practitioner and not the physician in the first thirty days of admission.
3. Review of Resident #64's medical record revealed an admission date of 10/09/23. Diagnoses included
acute kidney failure, hypertension, and heart failure.
Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 38 of 53
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
11/16/2023
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)
F 0712
cognitively intact.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #64's Physician Visit notes revealed Resident #64 was seen by the Nurse Practitioner
on 10/17/23, 11/12/23 and 11/15/23. No visits from the physician were found.
Residents Affected - Few
There was no evidence in Resident #64's medical record that Resident #64 was evaluated by a physician
during the resident's stay at the facility from 10/09/23 to 11/15/23.
Interview on 11/16/23 at 10:45 A.M. with the Director of Nursing (DON) verified Resident #64 had only been
seen by the Certified Nurse Practitioner and not the physician since 10/09/23 when Resident #64 was
admitted to the facility.
Review of the policy titled Physician Visits and Physician Delegation, revised October 2022, revealed the
physician should see the resident within 30 days of initial admission to the facility. At the option of the
physician, after the initial visit, the physician may alternate between personal visits by the physician and
visits by the physician assistant, nurse practitioner or clinical nurse specialist. The physician was required to
perform the initial comprehensive visit.
This deficiency is an example of continued noncompliance from the complaint survey dated 11/06/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 39 of 53
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
11/16/2023
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)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on staff interview, review of staffing schedules and payroll information, the facility failed to ensure
staffing included Registered Nurse in-house coverage was provided daily for eight consecutive hours during
a 24-hour period. This affected all 85 residents residing in the facility. The facility census in 85.
Findings include:
Review of facilit's master schedule obtained from payroll data between 08/13/23 and 11/13/23, noted the
facility staffing assignments lacking Registered Nurse (RN) coverage of eight hours during a 24-hour
period. These dates included the following: 08/24/23, 09/02/23, 09/03/23, 10/14/23, 10/28/23, 11/12/23.
Interview on 11/16/23 at 11:47 A.M., with Human Resources Director #207 confirmed responsibility for
developing and implementing facility nursing staff schedules. Review of nursing schedules and associated
payroll information between 08/13/23 and 11/13/23, Human Resources Director #207 verified the absence
of an RN scheduled for eight hours during a 24-hour period on 08/24/23, 09/02/23, 09/03/23, 10/14/23,
10/28/23, 11/12/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 40 of 53
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
11/16/2023
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and policy review, the facility failed to ensure
medications to address psychiatric diagnosis were monitored for effectiveness and specific treatment
outcome for specified condition. This affected one (#16) of five resident sampled residents reviewed for
unnecessary medications. The facility census was 85.
Findings include:
Review of Resident #16's medical record revealed an admission dated 11/05/14, with the diagnosis
including, schizophrenia, bipolar disorder, obsessive compulsive disorder, major depression, anxiety
disorder, insomnia, lumbosacral disc degeneration, malnutrition, anemia, chronic obstructive pulmonary
disease, and cachexia. According to the minimum data set assessment dated [DATE] Resident #16 was
assessed ability to make needs known, intact cognition, required set-up assistance for the completion of
activities of daily living, independent with toileting, continent of bowel and bladder, utilized a walker for
mobility, at risk for pressure ulcer development with no skin breakdown, and received the following high-risk
class medications, antipsychotic, antianxiety, antidepressant, and opioid.
Review of current physician orders revealed the following psychotropic medications: on 08/01/19 Ativan 0.5
mg by mouth two times a day for antianxiety; on 08/02/19 Paxil 10 mg by mouth one time a day for
antidepressant; 11/22/21 clozapine 50 milligrams (mg) by mouth one time a day for schizophrenia; and on
11/22/21 clozapine 200 mg by mouth at bedtime for schizophrenia.
Further review of the record lacked documentation related to specific indications or treatment outcomes
related to the administration of the psychotropic medications.
Observation on 11/14/23 at 9:06 A.M., noted Resident #16 in her room seated on bed. Interview with
Resident #16 revealed she attended an out of facility psychiatric treatment center every three months and
information is provided to the facility related to counseling sessions or treatments.
No documentation contained in the medical record revealed information was being maintained regarding
the use of psychotropic medications, counseling sessions, treatments outcomes or behavioral indications
regarding resident specific treatments. No documentation referenced the content related to the out of facility
psychiatric treatment center.
Review of the following plans of care revealed the following:
* Implemented on 04/19/21 risk for poor sleep pattern disturbance related to history of Insomnia due to
anxiety. Interventions included, Administer medications as ordered by physician. Monitor/document side
effects and effectiveness of each shift. Use of anti-anxiety medications related to anxiety disorder. Will be
free from discomfort or adverse reactions related to anti-anxiety therapy through the review date.
Administer antianxiety medications as ordered by physician. Monitor side effects and effectiveness of each
shift. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic
symptoms of anti-anxiety medication drugs being given.
* Revised on 06/06/22, resistive to care at times related to anxiety and schizophrenia disorder and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 41 of 53
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
11/16/2023
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
refused my medications occasionally. Interventions included, Allow the resident to make decisions about
treatment regime, to provide sense of control.
* Implemented on 04/19/23, Antidepressant medication related to Depression. Interventions included,
Administer antidepressant medications as ordered by physician. Monitor/document side effects and
effectiveness every shift. Educate the resident/family/caregivers about risks, benefits, and the side effects
and/or toxic symptoms of anti-depressant drugs being given.
* Implemented on 08/09/23 use of antipsychotic medications related to anxiety, depression, and
behavior/schizophrenia. Interventions included remain free of psychotropic drug related complications,
including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or
cognitive/behavioral impairment through review date. Administer psychotropic medications as ordered by
physician. Monitor side effects and effectiveness every shift. Antipsychotic medications are managed
through the out of facility behavioral health center. Resident arranges her own appointments and
transportation. Resident appointment frequency is determined by provider at behavioral health center.
Interventions included, Discuss with physician, family related to ongoing need for use of medication. Review
behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy.
Monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications: unsteady
gait, tardive dyskinesia, extrapyramidal symptoms (shuffling gait, rigid muscles, shaking), frequent falls,
refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision,
diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior
symptoms not usual to the person.
* Revised on 09/12/23 Ancillary services as dental. optical, audio, podiatry, and psych services. Intervention
included Social Services to set up ancillary services as needed and consented to. Residents attend the out
of facility behavioral health center and make their own appointments.
Review of behavior monitoring task documentation lacked specific behaviors monitored for related
medication effectiveness.
Interview on 11/15/23 at 1:00 P.M., with Licensed Practical Nurse (LPN) #175 during review of Resident
#16 medical record revealed no psychiatric related progress information or intended use were available
regarding psychiatric treatment including intended purpose of medications utilized to address behaviors.
LPN #175 was unaware of specific behaviors or indications Resident #175 was receiving psychotropic
medications.
Interview on 11/15/23 1:35 P.M., with the Director of Nursing confirmed Resident #16 attends outside
behavioral health center for psychiatric treatment. The behavioral health center will not release or provide
information specific to Resident #16 behavioral treatment or specific indications for use of prescribed
medications.
Interview on 11/15/23 at 3:25 P.M., with the Director of Nursing, during additional review of Resident #16
medical record and facility Use of Psychotropic Medication policy, confirmed specific use of medications are
to be monitored for effectiveness.
Review of the policy titled Use of Psychotropic Medication revised February 2023 noted indications for use
of any psychotropic drug will be documented in the medical record. Psychotropic drugs that are initiated to
the facility, documentation shall include specific condition as diagnosed by the physician.
Non-pharmacological interventions that have been attempted, and the target symptoms for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 42 of 53
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
11/16/2023
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
monitoring shall be included in the documentation. The resident response to the medication (s), including
progress towards goals and presence/absence of adverse consequences shall be documented in the
residents record.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 43 of 53
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
11/16/2023
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, medical record review, staff interview, and review of policy, the facility failed to
ensure medications were appropriately stored and secured. This affected one (#68) of one resident
observed with medications unattended at the bedside. The facility census was 85.
Findings include:
Review of the medical record revealed Resident #68 had an admission date of 08/03/22. Diagnoses
included rhabdomyolysis, chronic obstructive pulmonary disease, depression, and anxiety.
Review of the physician orders dated 06/25/23 revealed Resident #68 had an order for DuoNeb Solution
0.5-2.5 (3) milligrams (mg)/milliliter (ml), one inhalation orally via nebulizer three times a day for chronic
obstructive pulmonary disease.
Observation on 11/13/23 at 1:39 P.M., in Resident #68's room revealed there were two plastic vials of
DuoNeb solution left on the bedside table.
Interview on 11/13/23 at 1:42 P.M., Licensed Practical Nurse (LPN) #220 verified the medications were left
at the bedside. LPN #220 verified there was no order for the medication to be left at the bedside and the
resident had no orders to self-administer the medication.
Review of the policy Medication Administration, dated 2023, revealed staff would observe resident
consumption of medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 44 of 53
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
11/16/2023
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)
F 0806
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident and staff interviews, record review, and review of the resident council minutes, the
facility failed to ensure residents were provided with all reasonable ingredients during meal service. This
affected one Resident (#32) of six reviewed for food and had the potential to affect all residents except one
resident (#11) the facility identified as not receiving food by mouth (NPO). The facility census was 85.
Findings include:
Review of the medical record for the Resident #32 revealed an admission date of 03/20/23. Diagnoses
included acute appendicitis, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment
dated [DATE] revealed Resident #32 was cognitively intact.
Observation on 11/13/23 at 12:15 P.M. revealed hotdogs were served on a piece of bread instead of a
hotdog bun. Residents observed with a hotdog in a piece of bread included Residents #17, #20, #32, #36,
and #50.
Interview on 11/13/23 at approximately 1:30 P.M. with Director of Dining Services (DDS) #195 verified the
facility had run out of hotdog buns the evening prior and a delivery truck was due tomorrow that would
include hotdog buns. DDS #195 verified a slice of bread was substituted for hotdog bun and residents were
not reproached to inquire if they would like another meal option.
Interview on 11/13/23 at 4:30 P.M. with Resident #32 stated the facility runs out of food frequently and also
does not serve regular condiments such as butter with bread, jelly with toast, syrup with pancakes, and
cream and sugar with coffee. Resident #32 stated he regularly had to ask the aides or kitchen staff for
these items and many times they say no or they tell him they were out of the item. He also revealed he
ordered a hot dog and received it on a piece of bread/toast instead of a hot dog bun. He stated if he knew
they ran out of buns, he would not have ordered a hot dog.
Interview on 11/15/23 at 12:30 P.M. with State Tested Nursing Aide (STNA) #181 stated it was a common
occurrence for the kitchen to run out of the food or ingredients on the menu. She revealed it was also
common for the kitchen to not serve normal condiments such as not serving butter with bread or jelly and
butter with toast as well as no syrup with breakfast meals such as pancakes and condiments for coffee
(creamer and sugar).
Observation on 11/14/23 at 7:50 A.M. of breakfast in the dining room revealed oatmeal was being served to
residents. Several residents asking for sugar and toppings and these were not provided to any residents.
Staff had to return to the kitchen to get sugar after all trays were served. A resident was sitting in the dining
room with a two slices of dry toast, no butter or jelly was provided or available.
Interview on 11/14/23 at 7:55 A.M. with Dietary Staff #184 confirmed the residents were not served any
standard condiments for the breakfast meal until they asked for it.
Observation and interview on 11/16/23 at 8:07 A.M. revealed a resident was observed going down the
hallway and flagged a state surveyor down asking for jelly for his toast. Surveyor informed staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 45 of 53
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
11/16/2023
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)
F 0806
and jelly was obtained and provided at 8:14 A.M.
Level of Harm - Potential for
minimal harm
Review of the resident food council minutes dated 07/27/23, 08/17/23, 09/21/23, and 10/19/23 revealed
consistent concerns of residents not getting butter, not getting syrup for pancakes, not getting milk with
cereal, and missing food from trays. Follow ups have been completed related to resident concerns. On
08/22/23, Resident #32 reported it was better but staff were still missing syrup with pancakes. On 09/26/23,
audits were done of Resident #32's tray and found mishaps with missing butter.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 46 of 53
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
11/16/2023
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interviews, and review of the facility policies, the facility failed to ensure the
kitchen and food storage areas were maintained in a clean and sanitary manner. In addition, the facility
failed to ensure staff sanitized their hands prior to and during meal service and did not sanitize the hands of
the 17 residents in the memory care (#2, #5, #10, #13, #18, #22, #25, #27, #28, #43, #44, #45, #46, #60,
#65, #82, and #84; Resident #62 did not eat lunch.) prior to their lunch meal. This had the potential to affect
all residents except one resident (#11) who the facility identified as not accepting food by mouth. The facility
census was 85.
Findings include:
1. Observations on 11/13/23 at 8:50 A.M. of the kitchen and storage areas revealed the kitchen floor was
dirty with a layer of debris, dirt, and dust especially along the wall and under the storage open cabinet.
Observation of the walk in refrigerator revealed the shelving appeared to have a white mold like substance
and the floor was dirty. Further observation of the walk in refrigerator revealed an plastic bag of hotdogs
open to the air with no date. Observation of the walk in freezer revealed a bag of chicken breast was open
with no date and the freezer floor was dirty.
Interview on 11/13/23 at 9:15 A.M. with Director of Dining Services (DDS) #195 verified the kitchen areas of
the kitchen were not clean and sanitary, including the floor and refrigerator shelves and floor DDS #195
stated they had all been cleaned within the past week. DDS #195 verified the hotdogs and chicken breast
were not stored and labeled properly.
Review of the facility's policy titled Date Marking for Food Safety, dated 2023, revealed the food should be
clearly marked to indicate the date or day by which food shall be consumed or discarded.
Review of the facility's policy titled Sanitation Inspection, dated 2023, revealed the facility will conduct
inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and
federal regulations. All food service areas shall be kept clean, sanitary, free from litter, rubbish, and
protected from rodents, roaches, flies, and other insects.
2. Observation on 11/13/23 at 11:41 A.M. of the memory care lunch meal service revealed meal trays were
initially passed out to the six residents in the dining room and then all other residents received meal trays in
the resident rooms. No residents were asked or encouraged to hand sanitize prior to the lunch meal.
Observation of staff passing out meal trays revealed staff did not wash hands or hand sanitize between
passing out any of the dining room trays and only occasionally hand sanitized between passing out room
trays.
Interview on 11/13/23 at 11:49 A.M. with State Tested Nursing Assistant (STNA) #162 verified no residents
were asked or encouraged to sanitize/clean hands prior to the lunch meal and verified the aides did not
hand sanitize between passing each meal tray.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 47 of 53
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
11/16/2023
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)
F 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record reviews, review of the Certification And Survey Provider Enhanced Reports
(CASPER) Report, staff interviews, review of staff schedules, and review of the administrator's job
description, the facility failed to implement resources to ensure identified concerns were sufficiently
corrected and resident needs were adequately met. This affected five residents (#9, #39, #63, #64, and
#288) and had the potential to affect all 85 residents residing in the facility.
Residents Affected - Many
Findings include:
1. Review of the Certification And Survey Provider Enhanced Reports (CASPER) Report, dated 11/03/23,
revealed the facility had been cited at Data Tag F-689 (Free of accident hazards/Supervision/Devices)
during the annual surveys in February 2018, March 2019, and July 2021. Additional concerns at Data Tag
F-689 were identified during this recertification survey on 11/16/23.
Review of the CASPER Report, dated 11/03/23, revealed the facility had been cited at Data Tag F-561
(Self-Determination) on March 2019 and July 2021. Additional concerns at Data Tag F-561 were identified
during this recertification survey on 11/16/23.
2. Review of Resident #9's medical record revealed there were concerns related the physician's response
to notification of a change in Resident's health condition when the physician was paged on 11/04/23 for
Resident #9's at 1:00 P.M., 2:08 P.M., 3:18 P.M., and 6:08 P.M. with no return call received.
3. Review of Resident #288's medical record revealed there were concerns related to the physician and
facility nurse communicating about Resident #288's health concerns when the physician was paged on
11/08/23 at 4:36 P.M. and 6:45 P.M. and 11/12/23 at 10:52 A.M. and 4:25 P.M.
Interview on 11/15/23 at 9:17 A.M. with the Director of Nursing (DON) verified communicating with the
physician was an ongoing concern. The Administrator stated the facility had identified communication
between facility staff and physician had been a concern since approximately the month of July and
implemented a cordless phone. In addition, the facility had purchased disposable phones, but the nurses
had not been trained and were not yet in use.
4. Review of the medical records revealed concerns related to newly admitted residents (Residents #39,
#63 and #64) were not evaluated by a physician within thirty days of admission.
5. Review of the medical records revealed concerns related to nursing staff working outside their scope of
practice when not able to contact physician services. Review of the Resident #288's blood sugar levels
revealed on 11/08/23 at 4:34 P.M., 11/12/23 at 10:52 A.M. and 11/12/23 at 4:52 P.M. all were above 400
milligrams per deciliter (mg/dl).
Review of the progress notes, dated 11/08/23 and 11/12/23 revealed Licensed Practical Nurse (LPN) #175
was unable to contact the physician timely.
Interview on 11/15/23 at 9:00 A.M. with LPN #175 verified the physician order did not provide instructions to
administer insulin when Resident #288's blood sugar was over 400 mg/dl. When LPN #175 did not receive
a call back from the physician, LPN #175 opted to provided 10 units of insulin on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 48 of 53
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
11/16/2023
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)
F 0835
11/08/23 and 11/12/23.
Level of Harm - Minimal harm
or potential for actual harm
6. Review of facility master schedule obtained from payroll data between 08/13/23 and 11/13/23 noted the
facility staffing assignments lacking Registered Nurse (RN) coverage of eight hours during a 24-hour
period. These dates included the following: 08/24/23, 09/02/23, 09/03/23, 10/14/23, 10/28/23, and 11/12/23.
Residents Affected - Many
Interview on 11/16/23 at 11:47 A.M. with Human Resources Director #207 confirmed responsibility for
developing and implementing facility nursing staff schedules. Review of the nursing schedules and
associated payroll information between 08/13/23 and 11/13/23 verified the absence of an RN scheduled for
eight hours during a 24-hour period on 08/24/23, 09/02/23, 09/03/23, 10/14/23, 10/28/23, and 11/12/23.
Review of the Administrator Job Description revealed the purpose of the position is to establish and
maintain systems that are effective and efficient to operation of the facility in a manner to safely meet
resident's needs in compliance with federal, state, and local requirements.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 49 of 53
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
11/16/2023
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)
F 0847
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident interviews, staff interviews, review of the facility policy, and record review, the facility failed to
ensure the facility's arbitration agreement was thoroughly explained for complete understanding of the
agreement upon the residents' admission to the facility. The facility also failed to ensure the staff
responsible for the arbitration agreement was able to thoroughly explain the agreement for complete
understanding. This affected five (#8, #11, #52, #69, and #78) of five residents reviewed for binding
arbitration. This had the potential to affect the 59 residents who resided in the facility that entered into the
binding arbitration agreement. (Residents #1, #4, #5, #6, #7, #8, #9, #11, #12, #13, #15, #16, #17, #18,
#19, #20, #21, #24, #25, #28, #29, #30, #31, #35, #36, #37, #39, #40, #41, #42, #44, #45, #46, #48, #49,
#50, #51, #52, #54, #55, #56, #57, #58, #62, #63, #64, #65, #66, #68, #70, #71, #73, #75, #80, #81, #82,
#83, #289, and #388) identified to have signed arbitration agreements. The facility census was 85.
Residents Affected - Some
Finding include:
Review of the facility's list of resident's who signed the facility's binding arbitration agreement revealed
Residents #1, #4, #5, #6, #7, #8, #9, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #24, #25, #28, #29,
#30, #31, #35, #36, #37, #39, #40, #41, #42, #44, #45, #46, #48, #49, #50, #51, #52, #54, #55, #56, #57,
#58, #62, #63, #64, #65, #66, #68, #70, #71, #73, #75, #80, #81, #82, #83, #289, and #388 had signed
arbitration agreements.
1. Review of the medical record for Resident #8 revealed an initial admission date of 11/09/22 and
re-admission date of 12/16/22. Diagnoses included encephalopathy, altered mental status, dementia, and
spinal stenosis. Review of the Brief Interview of Mental Status (BIMS) assessment revealed Resident #8
had a score of six upon admission [DATE]) indicating Resident #8 had impaired cognition. Resident #8 had
quarterly BIMs assessments and the score ranged from four to 12. The most recent BIMS assessment
score was nine.
Review of the arbitration agreement dated 11/09/22 revealed Resident #8's signature page was not filled
out and Resident #8 did not sign the signature line of the agreement. The last page which included the
notice to rescind was also left blank. This included where the facility should place the date to which
Resident #8 would have to rescind the agreement and a signature from resident that they agree to the
30-day timeframe to rescind the arbitration agreement.
Interview on 11/15/23 at 11:05 A.M. during the resident council meeting with Resident #8 revealed she was
not informed of arbitration agreement and would not be interested in signing one if offered.
2. Review of the medical record for Resident #11 revealed an admission date of 01/18/23. Diagnoses
included cerebral palsy, diabetes type two, and dysphasia. Review of the BIMS assessment dated [DATE]
revealed Resident #11 had intact cognition.
Review of the signed arbitration agreement dated 04/19/21 revealed Resident #11 signed the arbitration
agreement. The last page which included the notice to rescind was not fully completed. This included where
the facility should place the date to which Resident #11 would have to rescind the agreement.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 50 of 53
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
11/16/2023
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)
F 0847
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview on 11/16/23 at 12:33 P.M. with Resident #11 revealed she had no recollection of receiving
education related to arbitration agreements and revealed she would not be agreeable to sign any type of
agreement waiving her rights.
3. Review of the medical record for Resident #52 revealed an admission date of 08/02/23. Diagnoses
included complete traumatic amputation at knee level, vascular disease, and chronic viral hepatitis C.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively
impaired with a BIMS score of nine.
Review of the signed Arbitration agreement dated 08/15/23 and 08/16/23 revealed Resident #52 signed the
arbitration agreement. The last page which included the notice to rescind was left blank. This included
where the facility should place the date to which Resident #52 would have to rescind the agreement and a
signature from resident that they agree to the 30-day timeframe to rescind the arbitration agreement.
Interview on 11/16/23 at 12:38 P.M. with Resident #52 revealed he had no recollection of receiving
education related to arbitration agreements and revealed he would not be agreeable to sign any type of
agreement waiving his rights.
4. Medical record reviews revealed Residents #69 was admitted on [DATE] and Resident #78 was admitted
on [DATE].
Interviews with Residents #69 and #78 during the resident council meeting on 11/05/23 at 11:06 A.M.
revealed they were not informed of the arbitration agreements and knew nothing about the process or what
they were. Both residents revealed they would not agree to sign an arbitration agreement if offered. Both
residents denied ever receiving education related to the arbitration agreements.
Interview on 11/16/23 at 12:13 P.M. with Admissions Director (AD) #117 revealed she would explain the
arbitration agreements and if residents did not want to sign they were not required. When asked to explain
the arbitration agreements and the process, AD #117 said they were a way to resolve disputes in a fair and
equitable manner for both sides. When asked if she informs residents they were waiving their rights to sue
the facility or have a jury trial if they take the facility to court, AD #117 stated she was uncertain of how this
was explained. When asked if she informs the residents they would not be able to sue the facility even in
cases of medical malpractice or wrongful death, AD #117 stated the facility's version of the arbitration
agreements were vague and did not spell out specifics such as medical malpractice or wrongful death.
Subsequent interview on 11/16/23 at 1:35 P.M. with AD #117 confirmed she was unaware of the second
page of the arbitration agreement where the concerns were bullet pointed dispute will be decided by
arbitration including property damage, personal injuries sustained by the resident, wrongful death and
medical malpractice. AD #117 confirmed her explanation had been vague and talked mainly using the term
disputes and not the blunt terminology used in the agreement.
Interview on 11/16/23 at 2:00 P.M. with the Administrator revealed her expectations were for residents to be
educated in terms they could understand what arbitration was and provided the paperwork to review and go
over with the AD.
Review of the facility policy titled Binding Arbitration Agreements, dated 2023, revealed the facility would
explain to the resident or representative in a language and manner they could understand and ensure
resident/representative acknowledge they understand the agreement.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 51 of 53
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
11/16/2023
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observations, resident and staff interviews, and policy review, the facility failed to maintain a
clean and sanitary environment. This affected seven (Residents #13, #21, #47, #48, #63, #79, and #80) of
30 residents reviewed for clean and sanitary environment. The facility census was 85.
Findings include:
1. Observation on 11/13/23 at 9:00 A.M. revealed peeling wall paper in the hallway leading to the employee
break room, peeling and torn wall paper to the left of the water fountain just outside the main dining room,
base board torn and pulled away from the wall to the right of the drinking fountain and a broken chair
labeled do not use broken sitting in front of the water fountain. The drinking fountain was covered with dust
and a crumbled tissue in the bowl of the fountain. Additional observation on 11/14/23 at 8:00 A.M. revealed
no changes to the items identified on 11/13/23.
Observations on 11/13/23 at 10:40 A.M. and on 11/14/23 at 11:00 A.M. of Resident #80's room revealed
broken blinds with missing and cracked slates on the right side and in the middle of the blinds covering the
window. Several dried, dead bugs in each corners of the window ledge.
Observations on 11/13/23 at 10:55 A.M. and on 11/14/23 at 10:50 A.M. of Resident #79's room revealed
peeling wallpaper under soap dispenser in bathroom. Cracked and crumbling floor tile along the seam one
tile row from the entrance to the bathroom. Three cigarette butts sat on the window ledge above the
resident's bed, and piles of clothing were on the floor along the wall opposite the door and on the chair just
outside the bathroom.
Observations on 11/13/23 at 11:10 A.M. and on 11/14/23 at 10:55 A.M. of Resident #63's bathroom
revealed the toilet bowl was pointed toward the door. Upon closer look, a bolt was broken on the left sided
base of the toilet was broken off and and laying on the base of the toilet. The toilet moved and tilted upon
touching.
Observations on 11/13/23 at 4:51 P.M. and on 11/14/23 at 10:53 A.M. of Resident #48's room revealed dirty
linens on the floor at the bathroom door and a missing toilet bolt on the right side of om bedside the toilet.
Tour completed on 11/14/23 between 11:15 A.M. and 11:30 A.M. with the Director of Housekeeping #152
verified the broken toilets in both Resident #48 and #63, the broken blinds and dead bugs on the window
ledge of Resident #80's room, the piles of dirty clothes in Resident #79 and #80's room, the cigarette butts,
cracked crumbling floor tile and peeling wallpaper in the room of Resident #79's room and the broken chair,
dusty covered water foundation and the tissue on top of the water foundation and the peeling wallpaper in
the hallway near the water foundation and the employee break room as well as the torn baseboard on the
wall to the right of the drinking fountain.
2. Observation and interview on 11/13/23 at 10:57 A.M. revealed Resident #21's bathroom had a shower
and the shower area had broken tiles that had fallen off the wall and were on the floor of the shower area
which was a accident hazard. Resident #21 stated he used the bathroom and shower area regularly.
Observation and interview on 11/14/23 at 12:23 P.M. with Maintenance #138 confirmed Resident #21
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 52 of 53
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
11/16/2023
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
had shower wall tiles that had broken off the wall and fallen to the floor in the shower area. Maintenance
#138 confirmed this has been a problem and the facility planned to renovate the rooms. Maintenance #138
confirmed the tiles should be picked up off the floor for safety, but did not pick them up at this time and tiles
were left on the floor after confirmation.
3. Observation and interview on 11/13/23 at 10:11 A.M. revealed Resident #47's bathroom had a shower
and the shower area had broken tiles that had fallen off the wall and were on the floor of the shower area
which was an accident hazard. Resident #47 stated he used the bathroom and shower area regularly.
Resident #47's toilet also had dark brown fuzzy material in the toilet bowl under the water line and dried
urine on the seat and dried brown splatter material on the back of the toilet seat.
Observation and interview on 11/14/23 at 12:23 P.M. with Maintenance #138 confirmed #47 had shower
wall tiles that had broken off the wall and fallen to the floor in the shower area. Maintenance #138
confirmed this has been a problem and facility planned to renovate the rooms. Maintenance #138
confirmed the tiles should be picked up off the floor for safety, but did not pick them up at this time and tiles
were left on the floor after confirmation. Maintenance #138 also confirmed the brown fuzzy material was
likely poop, Maintenance #138 flushed it did not go down the toilet plumbing. He revealed it was likely from
lack of thorough cleaning as well as the dirty toilet seat.
4. Interview and observation on 11/13/23 at 4:10 P.M. with Resident #13 revealed the facility was unclean
including the resident's room. Resident #13's room had dirt and debris throughout the floor. On the wall next
to the resident's bed, there was an unidentified splatter. The trim near the bathroom door was missing and
wall plaster was crumbling off.
Interview on 11/14/23 at 1:30 P.M. with State Tested Nursing Assistant (STNA) #162 verified Resident #13's
room was unclean. STNA #162 stated the splatter on the wall next to Resident #13's bed was likely feces
and did not know how long it had been there. STNA #162 verified the facility was not cleaned well or
thoroughly.
Review of the facility policy titled Safe and Homelike Environment, dated 2023, revealed the facility will
provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will
be provided as necessary to maintain a sanitary, orderly and comfortable environment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365898
If continuation sheet
Page 53 of 53
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Back to topCitations
48 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
F571 - The facility must not impose a charge against the personal funds of a
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F710 - Physician Services
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
F712 - Frequency of physician visits
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0753GeneralS&S Epotential for harm
Have restrictions on the use of highly flammable decorations.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the November 16, 2023 survey of DIVINE REHABILITATION AND NURSING AT SYLVANIA?
This was a inspection survey of DIVINE REHABILITATION AND NURSING AT SYLVANIA on November 16, 2023. The surveyor cited 48 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DIVINE REHABILITATION AND NURSING AT SYLVANIA on November 16, 2023?
Yes, 48 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide enough food/fluids to maintain a resident's health."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.