Inspection·July 22, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on [DATE] at 5:53 A.M. Review of the facility timeline, based on review of facility video footage, revealed on 07/12/25 at 6:09 P.M., another resident was observed taking Resident #01 outside to the smoking patio. Resident #01 was observed outside on the patio either by himself or with other residents present throughout the evening. At 10:48 P.M. an unidentified nurse was observed assisting another resident on the smoking patio. Further review of the timeline revealed on 07/13/25 at 12:00 A.M., 1:13 A.M., 2:00 A.M., 3:00 A.M., 4:00 A.M., and 5:00 A.M., Resident #01 was outside (on the smoking patio) with no staff present. At 5:51 A.M., CNA #133 retrieved Resident #01 from the patio. Review of an additional facility timeline document, dated 07/12/25 to 07/13/25, revealed on 07/12/25 at 5:21 P.M., Licensed Practical Nurse (LPN) #154 passed medications at dinnertime. No medications were administered to Resident #01. Medications, which were due at 6:00 P.M., 9:00 P.M., and 10:00 P.M., were signed out (as administered) by RN #241 for Resident #01 at 1:32 A.M. According to the facility timeline, multiple residents continued in and out of the patio until 1:45 A.M. At 6:29 A.M., Certified Nursing Assistant (CNA) #243 marked Resident #01 as unavailable for incontinence care in tasks (CNA documentation system). Review of a witness statement, dated 07/13/25, revealed CNA #243 began work on 07/12/25 at 10:33 P.M. and did not receive report from the nurse or the aide that Resident #01 had moved rooms. CNA #243 stated she had been off for three days and during her previous shift Resident #01 was on a different hall. Review of an electronic mail (email) witness statement, dated 07/16/25, revealed RN #242 reported Resident #01 did not received medication on her scheduled shift (07/12/25 6:00 P.M. to 10:00 P.M.) due to the report that he had eaten more than 50% of his dinner meal, therefore, a bolus feeding was not required and the next medication administration would have been at 10:00 P.M. RN #242 stated she had informed the next nurse of the situation. Review of an email witness statement, dated 07/14/25, revealed RN #241 stated Resident #01 received his medication while in the dining room watching a card game. Review of a written witness statement, dated 07/15/25, revealed CNA #189 worked on 07/12/25 beginning at 2:30 P.M. and completed the first rounds at 3:00 P.M. CNA #189 stated Resident #01 was in the dining room and at the next rounds, he was in the smoking area (outside patio). When in the dining room, CNA #189 had asked if he wanted to use the bathroom and Resident #01 had declined. Review of text message witness statement, unknown date, revealed CNA #133 worked on 07/12/25 beginning at 10:30 P.M. and was not assigned to Resident #01. At the time of the last rounds, she was notified by a nurse that Resident #01 was not in his room and had been sitting outside for the entirety of the night. CNA #133 retrieved the resident from outside and took him back to the resident's room. CNA #133 stated Resident #01 required a Hoyer lift for transfers and the nurse instructed her to wait until the assigned aide came to provide care. Review of resident witness statements, dated 07/15/25, revealed Residents #21, #32, #47, #50, and #77 were outside on the smoking patio at times throughout the evening of 07/12/25. The residents reported Resident #01 remained to himself. Resident #21 reported the only time he spoke to Resident #01 was when he gave him a cigarette. Interview on 07/21/25 at 9:30 A.M. with the Administrator verified Resident #01 was left outside all night on 07/12/25 and into the morning of 07/13/25, without staff supervision. The Administrator revealed Resident #01 could maneuver himself (in a wheelchair) for short distances but would not be able to transport himself from inside the facility to the smoking area or from the smoking patio back into the facility due to the small lip (bump) in the flooring at the doorway. A follow-up interview at 10:43 A.M. with the Administrator verified, based on review of the facility's video camera footage, Resident #01's medications were signed off and not passed during the evening of 07/12/25. The Administrator verified the resident had not received incontinence care or medication administration from at least 07/12/25 at 6:09 P.M. to 07/13/25 at 5:53 A.M. Interview on 07/21/25 at 10:45 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366328 If continuation sheet Page 2 of 6 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 366328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Toledo 1011 North Byrne Road Toledo, OH 43607 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A.M. with Resident #01 verified he had been left outside all night on 07/12/25, stating they had forgotten about him. Resident #01 stated he was not scared and he watched the cats and slept a little in his wheelchair. Resident #01 denied any pain, skin breakdown, or any other negative outcome as a result of the incident. Interview on 07/21/25 at 4:14 P.M. with the Director of Nursing (DON) revealed that through the facility investigation, they were able to verify Resident #01's physician ordered g-tube flush and medications were documented as completed on the MAR on the evening shift of 07/12/25; however, the g-tube flush and medications were not administered as ordered. A telephone interview on 07/22/25 at 11:48 A.M. with CNA #189 verified working on 07/12/25 from 2:00 P.M. to 10:00 P.M. and being assigned to Resident #01. CNA #189 stated she had not previously provided care for Resident #01 and had thought he was more independent than he was. CNA #189 believed the resident could verbalize his needs and could propel himself in his wheelchair. CNA #189 stated she had asked him if he needed to use the restroom shortly after 3:00 P.M. and he had stated no. CNA #189 stated she had observed Resident #01 on the smoking patio and had thought he wheeled himself outside. CNA #189 verified she did not provided incontinence care to Resident #01 during her shift from 2:00 P.M. to 10:00 P.M. on 07/12/25. CNA #189 revealed she had since learned that Resident #01 could not propel himself and did not verbalize his needs. A telephone interview on 07/22/25 at 2:11 P.M. with RN #242 verified working on 07/12/25 from 6:00 P.M. to 10:00 P.M. RN #242 further confirmed she did not administer any medications or treatments to Resident #01. RN #242 stated she observed Resident #01 sitting outside (on the smoking patio) at approximately 8:30 P.M. or 9:00 P.M RN #242 stated she provided report to the oncoming nurse (RN #241), stating she told her where he was and what he needed. Review of the facility policy titled, Routine Resident Checks, dated July 2013, revealed to ensure the safety and well-being of residents, nursing staff shall make a routine resident checks on each unit at least once per each eight hour shift. Routine resident checks involved identifying if the resident needs were being met.Review of the facility policy titled, Accidents and Supervision, dated 2024, revealed the resident environment would remain as free from accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. Supervision was an intervention and a means of mitigating accident risk. The facility would provide adequate supervision to prevent accidents. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 2024, revealed the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation. This deficiency represents non-compliance investigated under Complaint Number 2565468. Event ID: Facility ID: 366328 If continuation sheet Page 3 of 6 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 366328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Toledo 1011 North Byrne Road Toledo, OH 43607 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to report allegations of neglect timely to the State Survey Agency (SSA). This affected one (#01) of three residents reviewed for abuse and neglect. The facility census was 73. Findings include: Review of the medical record review revealed Resident #01 was admitted on [DATE]. Diagnoses included cerebral infarction (stroke), traumatic hemorrhage of cerebrum, difficulty in walking, anxiety disorder, unspecified urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence.Review of the Minimum Data Set (MDS) assessment, dated 04/25/25, revealed the resident was moderately cognitive impaired. Resident #01 was always incontinent of bowel and bladder and dependent on care for toileting and chair to bed transfers. Review of a nursing progress note, dated 07/13/25 at 6:59 A.M., revealed Resident #01 was not in his room at the time the writer attempted to administer his medications. On inquiry, another resident stated he was outside in the smoke area where he had been all night. Facility staff were immediately sent to bring the resident inside the facility. The writer (Registered Nurse [RN] #241) inquired from the resident as to why he remained outside during the night and he replied that he was cleaning. The resident could have periods of confusion. Review of a facility submitted SRI, created on 07/15/25, revealed an allegation of neglect was discovered on 07/13/25 when Resident #01 was left outside on the smoking patio for an extended period of time, without staff supervision or personal care provided. Review of the facility summary investigation, dated 07/17/25, revealed the investigation was ongoing through 07/15/25 and reported untimely to the SSA. Interview on 07/21/25 at 9:30 A.M. with the Administrator verified the incident involving Resident #01 was discovered on 07/13/25 and not reported to the SSA until 07/15/25. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 2024, revealed the facility would report all alleged violations immediately, but not later than two hours after the allegation was made if the events that caused the allegation involved abuse or resulted in bodily injury or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in bodily injury. This deficiency represents non-compliance investigated under Complaint Number 2568168. Event ID: Facility ID: 366328 If continuation sheet Page 4 of 6 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 366328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Toledo 1011 North Byrne Road Toledo, OH 43607 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 medical record review, staff interview and review of facility policy, the facility failed to ensure smoking assessments were completed for residents who smoked. This affected one (Resident #01) of three residents reviewed for smoking. The facility census was 73. Findings include:Review of the medical record revealed Resident #01 was admitted on [DATE]. Diagnoses included cerebral infarction (stroke), traumatic hemorrhage of cerebrum, difficulty in walking, anxiety disorder, unspecified urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence.Review of the Minimum Data Set (MDS) assessment, dated 04/25/25, revealed the resident was moderately cognitive impaired. Resident #01 was always incontinent of bowel and bladder and dependent on care for toileting and chair to bed transfers. Review of the care plan, dated 07/15/25, revealed Resident #01 was a smoker and interventions included to determine if the resident had a desire to quit, instruct resident on the facility smoking policy, educate on risks and health effects, provide support, and if the resident would like to quit, contact provider. Review of the Smoking Safety Screen, dated 07/15/25, revealed Resident #01 smoked one to two cigarettes a day, typically in the evening, and could not light his own cigarette. Resident #01 was determined to be safe to smoke without supervision. Resident #01 states he only smokes occasionally.Further review of Resident #01's medical record revealed no evidence a Smoking Safety Screen had been completed prior to 07/15/25.Interview on 07/22/25 at 10:47 A.M. with the Administrator verified a smoking assessment had not been completed for Resident #01 until 07/15/25. The Administrator stated the facility was unaware Resident #01 was a smoker until she watched facility camera footage on 07/13/25, related to an investigation she was conducting regarding Resident #01 being left on the smoking patio overnight, and observed him smoking outside. Review of the facility policy titled, Resident Smoking, dated 2024, revealed all residents would be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. Residents who smoked would be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision was required for smoking, or if the resident was safe to smoke at all. This deficiency is an example of continued non-compliance from the surveys dated 05/22/25 and 07/02/25. Event ID: Facility ID: 366328 If continuation sheet Page 5 of 6 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 366328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Toledo 1011 North Byrne Road Toledo, OH 43607 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility submitted Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to ensure accurate medical records. This affected two (Resident #01 and #21) of three residents reviewed medical record documentation. The facility census was 73. Findings include:1) Review of the medical record revealed Resident #01 was admitted on [DATE]. Diagnoses included cerebral infarction (stroke), traumatic hemorrhage of cerebrum, difficulty in walking, anxiety disorder, unspecified urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence.Review of the Minimum Data Set (MDS) assessment, dated 04/25/25, revealed the resident was moderately cognitive impaired. Resident #01 was always incontinent of bowel and bladder and dependent on care for toileting and chair to bed transfers. Review of the July 2025 Medication Administration Record (MAR) revealed on the nightshift on 07/12/25, the following medications were documented as administered via gastrostomy tube (g-tube - tube inserted through the abdominal wall and into the stomach, used to deliver nutrition, fluids, and medications) to Resident #01: atorvastatin calcium (hyperlipidemia) 10 milligram (mg), buspirone (anxiety) 10 mg, losartan potassium (hypertension) 100 mg, mirtazapine (depression) 15 mg, carvedilol (hypertension)12.5 mg, levetiracetam solution (seizure disorder) 5 milliliters (ml), magnesium supplement 400 mg, polyethylene glycol packet (constipation), senna tablet (constipation), sodium chloride (hyponatremia), and baclofen (muscle relaxer) 15 mg. Additional review of the MAR for 07/12/25 revealed that Resident #01 received an enteral feed after meals if the resident consumed less than 50% of the meal offered. Jevity (nutritional supplement) was documented as administered at 6:00 P.M. Further review of the MAR revealed Resident #01's g-tube was to be flushed every 12 hours with 60 ml of water to maintain patency. This was documented on the MAR as completed at 8:00 P.M. Additionally, a house supplement was ordered and marked as received, an order for Zyprexa (behaviors/mood affective disorder) 5 mg was documented as refused. Lastly, the MAR included documented blood pressure and pulse for Resident #01 on 07/12/25 nightshift. Interview on 07/21/25 at 9:30 A.M. with the Administrator verified Resident #01 was not administered any medication or treatments from at least 07/12/25 at 6:09 P.M. to 07/13/25 at 5:53 A.M. and further confirmed the nurse had falsified the MAR. Interview on 07/21/25 at 4:14 P.M. with the Director of Nursing (DON) verified that through the facility's investigation into a neglect allegation, it was found that Resident #01's physician ordered g-tube flush and medications were documented as completed; however, the facility determined the treatment and medication had not been provided as ordered. 2) Review of the medical record revealed Resident #21 was admitted on [DATE]. Diagnoses included Type II diabetes mellitus without complications, chronic obstructive pulmonary disease (COPD), unspecified dementia, essential hypertension, and hyperglycemia. Review of the MDS assessment, dated 04/30/25, revealed the resident was cognitively intact. Review of the MAR, dated July 2025, revealed an order for a weekly skin assessment every night shift, every Saturday was signed off as completed on 07/05/25, 07/12/25, and 07/19/25.Review of skin assessments from June 2025 and July 2025 revealed no evidence Resident #21 had a skin assessment completed since 06/21/25. Interview on 07/21/25 at 4:14 P.M. with the DON verified Resident #21's skin assessment had not been completed as documented as completed on the MAR. Interview on 07/22/25 at 10:47 A.M. with the Administrator verified Resident #21 had not had a skin assessment completed since 06/21/25 and the documentation on the MAR indicated it was completed on 07/05/25, 07/12/25, and 07/19/25. This deficiency represents non-compliance investigated under Complaint Number 2568168. Event ID: Facility ID: 366328 If continuation sheet Page 6 of 6