Inspection·October 27, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to be canceled as the facility provided the resident breakfast that morning. The procedure was rescheduled for 10/09/25. On 10/08/25, RN #200 stated she contacted the facility to ensure pre-procedure instructions were followed, including the holding of Eliquis and aspirin for three days prior to the procedure, and discovered the facility did not hold the resident's medication, as instructed. Resident #56's bone marrow biopsy had to be rescheduled for a second time due to the facility not following pre-procedure orders. Additional review of the October 2025 MAR confirmed Resident #56 was administered aspirin and Eliquis on 10/06/25, 10/07/25, and 10/08/25. Interview with Licensed Practical Nurse (LPN) #305 on 10/20/25 at 11:56 A.M. revealed that when a resident returned to the facility with new orders for a procedure, the information was placed in the MAR, and the physician was notified. LPN #305 stated the facility did not have hard/paper charts, so there were delays in uploading important documents into the electronic medical record (EMR). LPN #305 stated report between nurses was verbal, and they had a report sheet. LPN #305 confirmed Resident #56 ate before his appointment on 10/01/25, and that the second appointment on 10/09/25 was cancelled due to staff administering aspirin and Eliquis to Resident #56, and not holding it for three days prior, as instructed. Interview with Director of Nursing (DON) on 10/20/25 at 2:25 P.M. revealed the floor nurse would have been the staff who received the orders for Resident #56's bone marrow biopsy preparation. The DON confirmed that there were no orders in the EMR for the pre-procedure instructions for the bone marrow biopsy scheduled for 10/01/25, resulting in staff providing the resident breakfast on 10/01/25 and cancellation of the procedure. The DON further verified pre-procedure instructions were not followed for the bone marrow biopsy scheduled for 10/09/25 and the staff administered Resident #56's Eliquis and aspirin, resulting in the procedure being rescheduled for 10/21/25. The DON stated dietary staff were verbally informed of any NPO orders, but there should be a more formal process in place to avoid potential issues, like in the case with Resident #56 being served his breakfast meal on 10/01/25. Interview with RN Unit Manager (RN/UM) #306 on 10/22/25 at 2:47 P.M. revealed when a resident returned from an appointment, the nurse received the after-visit packet. The nurse providing care for the resident was supposed to review the information and enter any new orders into the EMR. RN/UM #306 confirmed this was not completed for Resident #56's procedures. This deficiency represents non-compliance investigated under Master Complaint Number 2639137. Event ID: Facility ID: 366328 If continuation sheet Page 2 of 7 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 10/27/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of hospital documentation, staff interview, and review of facility policy, the facility failed to ensure timely assessment, measurement, and documentation of wound descriptions were completed and further failed to ensure physician ordered treatments and skin impairment interventions for a right heel pressure ulcer were initiated timely and completed as ordered. This affected one (#71) of three residents reviewed for pressure ulcers. The facility census was 71.Findings include:Review of the closed medical record for Resident #71 revealed an admission date of 08/01/25. Diagnosis included anemia, Type II diabetes mellitus, and chronic kidney disease. Resident #71 transferred to the hospital on [DATE] due to a change in condition and did not return to the facility.Review of the admission Minimum Data Set (MDS) assessment, dated 08/05/25, revealed Resident #71 was cognitively intact. Resident #71 was assessed to have one venous wound, one stage IV pressure ulcer, and one unstageable pressure ulcer.Review of the care plan dated 08/11/25 revealed Resident #71 required staff intervention to complete self-care and mobility activities and was at risk for decline in functional ability and usual performance. Interventions included assisting with ADLs. Additionally, Resident #71 had diabetes mellitus. Interventions included checking all of body for breaks in skin and treating promptly as ordered by a doctor. Further review revealed Resident #71 had a stage four pressure ulcer to the left distal knee, a stage three pressure ulcer to left lower thigh, and the potential for pressure ulcer development related to the disease process of diabetes mellitus. Interventions included assessing, recording, and monitoring wound healing two times a week on Monday and Thursday, measuring the length, width and depth where possible, assessing and documenting the status of the wound perimeter, wound bed and healing progress, and report improvements and decline to the doctor. Lastly, Resident #71 had a venous ulcer of the left shin related to diabetes mellitus Type II, and moisture associated skin damage (MASD) to the coccyx. Interventions included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, and type of tissue exudate (drainage), and any other notable changes or observations.Review of a nursing progress note dated 08/02/25 at 4:34 P.M. revealed Resident #71 arrived to the facility from an acute care hospital. Resident #71 had a left below the knee amputation with a prosthetic leg. Resident #71 had wounds to the left stump, front of thigh, and lateral thigh. Lastly, the progress note indicated Resident #71's right leg had healing scars to the knees and black eschar (layer of dead tissue that forms over a wound) to the heel and second toe. Further review of the medical record revealed no evidence the wound to Resident #71's right heel and second toe were assessed, including further description and measurements of the wounds.Review of the physician orders dated 08/03/25 revealed an order for offloading pressure boots in place at all times while Resident #71 was in bed and document all refusals. Additionally, Resident #71 had an order for skin prep to the right heel every day and as needed.Review of the Skin Observation Tools revealed that on 08/08/25, Resident #71 was assessed to have a left below the knee amputation and left lower shin vascular wound (the resident's left leg was amputated below the knee). There was no assessment of the right heel pressure ulcer. Further review revealed on 08/15/25, Resident #71's skin was marked to be intact. There was no assessment of the right heel pressure ulcer. On 08/22/25, the assessment indicated Resident #71 had a pressure wound to the left lower thigh and the left distal knee, with a vascular wound to the left shin (the resident had a left below the knee amputation). There was no assessment of the right heel pressure ulcer. Additional review of the Skin Observation Tools revealed no skin assessment was completed from 08/22/25 through 09/23/25. Review of the Skin Observation Tool completed on 09/24/25 revealed Resident #71 had a pressure wound to the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366328 If continuation sheet Page 3 of 7 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 10/27/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left distal knee and left lower thigh, and a vascular wound to the left shin (resident had a below the knee amputation). There was no assessment completed for the resident's right heel pressure ulcer.Review of the Treatment Administration Record (TAR) for August 2025 revealed no documentation that the skin prep was applied to Resident #71's right heel on 08/14/25, 08/15/25, and 08/20/25. Further review of the TAR for August 2025 revealed no documentation the offloading pressure boots were in place on 08/06/25 and 08/16/25 at nighttime or on 08/14/25, 08/15/25 and 08/20/25 during the day. There was no documentation that Resident #71 refused treatments. Review of the Wound Care Notes from 08/07/25 through 09/08/25 revealed Resident #71 was seen weekly by wound care for the management and treatments of wounds; however, there was no mention of the resident's right heel. Review of the September 2025 TAR revealed no evidence skin prep was applied to Resident #71's right heel on 09/01/25, 09/04/25, and 09/10/25. Further review of the TAR for September 2025 revealed no documentation the offloading pressure boots were in place on 09/01/25, 09/10/25, and 09/16/25 during the day or on 09/12/25 during the night. There was no documentation that the resident refused treatment.Review of a nursing progress note, dated 09/11/25 and completed by Licensed Practical Nurse (LPN) #303, revealed new order per wound care, site now open. Further review revealed no description of the wound's location, measurements of the wound, or any other characteristics of the wound referenced in the progress not.Review of a physician order dated 09/11/25 revealed an order for Hydrofera blue (antibacterial foam dressing) to the right heel wound bed, wrap with Kerlix (gauze bandage roll used in wound care), as needed (PRN), and discontinue skin prep to the right heel. Review of the September 2025 TAR revealed no evidence that the new wound treatment order was completed on 09/11/25 or 09/12/25. Further review of the physician orders revealed on 09/13/25, the order for Hydrofera blue and wrap with Kerlix was changed to three times weekly and PRN. Review of the September 2025 TAR confirmed the wound treatment for Resident #71's right heel wound was not initiated until 09/13/25.Review of a nursing progress note dated 09/15/25 revealed the wound care manager and wound doctor rounded on the resident, a new area was noted to the right heel exacerbated, continue all treatment orders for all previous areas as prescribed, and a new order was received for and offloading boot to the right lower extremity as tolerated daily.Review of the Wound Care Note dated 09/15/25 revealed Resident #71 had a new stage three pressure wound of the right heel, full thickness, measuring four centimeters (cm) by (x)15 cm by 0.3 cm, with a surface area of 60 cm. The wound was noted to have moderate serous exudate and no signs of infection. Treatment orders were continued. Review of a Wound Care Note dated 09/22/25 revealed Resident #71 had a right heel pressure ulcer that measured four cm x 13 cm x 0.3 cm, with a surface area of 52 cm. The wound had moderate serous exudate and there were no signs of infection. Treatment orders were continued.Review of a nursing progress note dated 09/26/25 at 12:26 P.M. revealed Resident #71 was sent to the Emergency Department (ED) due to the resident's report of seeing double visions and hallucinations. Upon assessment, Resident #71 appeared to be experiencing edema on the left side and appeared to be physically weaker than his baseline. The Nurse Practitioner (NP) was contacted, and it was recommended for the resident to be sent out to hospital via nonemergent transport.Review of ED notes, dated 09/26/25, revealed Resident #71 was seen for leg swelling and left arm swelling. Resident #71 was admitted for sepsis, right heel gangrene, acute pneumonia, urinary tract infection, abdominal ileus, congestive heart failure, and left upper extremity and left lower extremity edema. Further review of an ED nursing progress note addendum, dated 09/26/25 at 9:15 P.M., revealed multiple wounds were observed on assessment. While unwrapping Resident #71's right heel, multiple maggots/larvae were observed coming from the wound. With the assistance of a second nurse, the wound was irrigated with saline. About six to seven maggots/larvae were flushed from the wound, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366328 If continuation sheet Page 4 of 7 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 10/27/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and the right heel was rewrapped with gauze. Review of a nursing progress note dated 09/27/25 at 7:34 A.M. revealed the nurse spoke with an ED nurse who reported that Resident #71 seemed confused, and they had found six maggots in the resident's wound. Interview on 10/21/25 at 3:24 P.M. with the facility's wound care nurse, LPN #303, revealed Resident #71 admitted to the facility with multiple wounds. LPN #303 stated Resident #71 received skin prep daily to the right heel due to the heel being soft. LPN #303 verified the facility had no evidence the right heel wound was being monitored or assessed from the time of admission on [DATE] until the resident was seen by the wound care physician on 09/15/25, and further confirmed nursing should have monitored and assessed the area. LPN #303 stated that on 09/11/25, a nurse aide reported that she attempted to remove Resident #71's sock and the resident's skin began to peel off with the sock. LPN #303 stated she removed the sock, which exposed a large open area to the resident's right heel. LPN #303 stated she called the wound physician, received new orders, and Resident #71 was going to be further evaluated by the physician the following day. LPN #303 confirmed she did not document an assessment of the wound on 09/11/25 and the facility had no evidence the treatment ordered on 9/11/25 was initiated until 09/13/25. A follow-up interview on 10/23/25 at 9:34 A.M. with wound nurse LPN #303 confirmed skin checks were supposed to be conducted weekly, and these were usually set up by the unit managers on a resident's shower day. LPN #303 verified Resident #71 did not have any orders for weekly skin checks and further confirmed the facility had no evidence weekly skin checks were completed from 08/22/25 until 09/24/25. Additionally, LPN #303 verified that the skin checks that were completed on 08/08/25, 08/15/25, 08/22/25, and 09/24/25 failed to identify and assess the wound to Resident #71's right heel. LPN #303 further verified that the facility did not have evidence skin prep to Resident #71's right heel was completed on 08/14/25, 08/15/25, 08/20/25, 09/01/25, 09/04/25, and 09/10/25 and no documentation of offloading pressure boots being in place on 08/06/25 at night, 08/14/25 and 08/15/25 during the day, 08/16/25 at night, and 08/20/25 during the day.Interview on 10/23/25 at 10:29 A.M. with Wound Physician (WP) #400 revealed Resident #71 was seen last on 09/22/25, and the wound on the heel was debrided (not documented in the wound care notes). WP #400 stated Resident #71 most likely had a deep tissue injury on the right heel prior to its opening. WP #400 stated the staff should have been applying the skin prep to the right heel and allowing it to completely air dry before putting socks back on, and, most likely what happened was the skin prep did not completely dry and the sock stuck to the heel, removing a layer each time his socks were removed. WP #400 stated necrosis can set in within a couple of hours, if not properly treated. WP #400 stated Resident #71 may have had slough (buildup of dead tissue) on his right heel upon admission and could not recall any assessment or monitoring of the right heel, or any treatments other than skin prep and offloading boots. Interview on 10/23/25 at 2:00 P.M. with the Administrator confirmed that weekly skin checks should have been completed by nursing for Resident #71 and further confirmed that the skin checks that were documented included no mention of skin issues to the resident's right heel. Review of the facility policy titled, Wound Treatment Management, dated 2024, revealed treatments would be documented on the treatment administration record in the electronic health record. The effectiveness of treatments would be monitored through ongoing assessment of the wound. Considerations for needed modifications included lack of progression towards healing, and changes in the characteristics of the wound. This deficiency represents noncompliance investigated under Complaint Numbers 2636464 and 2630303. Event ID: Facility ID: 366328 If continuation sheet Page 5 of 7 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 10/27/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of pest control records, staff and resident interview, and review of the facility policy, the facility failed to ensure effective pest control in the facility. This affected two (#14 and #19) of three residents reviewed for pest control, and had the potential to affect all 71 residents residing in the facility. The facility census was 71.Findings include:Interview on 10/22/25 at 8:19 A.M. with Registered Nurse (RN) #307 revealed there were an excessive number of flies on the 100 and 200 halls. RN #307 stated the facility had fly swatters on the nurses' carts and in the residents' rooms due to the large number of flies in the facility.Interview on 10/22/25 at 8:55 A.M. with Licensed Practical Nurse (LPN) #301 revealed the facility had flies and gnats so bad that the nurses carried fly swatters during medication pass, and the residents that could use their hands had them in their room. LPN #301 stated there were times when staff would have to swat the flies away from resident's faces who were unable to swat them away themselves. LPN #301 stated the flies had been reported to management and administration. LPN #301 stated there was a mouse in the activities room and on one occasion the activities aide ran out screaming after seeing a mouse.Interview on 10/22/25 at 9:46 A.M. with LPN #309 revealed there were mice in the facility and she had seen them in Resident #14's room. LPN #309 revealed she had bought her own mouse traps and gave them to maintenance to put around due to the facilities pest control not being effective. LPN #309 stated Resident #14 had reported mice in his room to administration.Observation on 10/22/25 at 10:10 A.M. of Resident #14's bedroom revealed multiple flies and gnats in the bedroom. Further observation revealed several flies on the residents' drinking cups and on the bedside table. Concurrent interview with Resident #14 revealed that around 10/19/25, there was a mouse on his bed and, later in the day, a mouse was in front of his chair. Resident #14 stated he reported it to the nurse. Resident #14 stated maintenance came to his room and sprayed peppermint oil around the walls of the bedroom.Interview on 10/22/25 at 10:20 A.M. with Resident #49 revealed a mouse came into his room every day. Resident #49 stated he had reported it to the nurses.Interview on 10/22/25 at 11:16 A.M. with Director of Maintenance (DM) #401 verified mice had been a concern in the facility and stated it had been hard to get rid of the mice in Resident #14 and Resident #49's rooms. DM #401 stated the pest control vendor had been to the facility on [DATE] for a consultation and provided an estimate for a more aggressive treatment for mice. DM #401 stated the facility chose to try to treat them on their own with an organic peppermint oil spray. DM #401 stated on 10/20/25, Resident #14 and Resident #49's rooms were sprayed with the peppermint oil and staff still reported mice sightings. DM #401 stated that the continued rodent activity would need to be taken care of in a more aggressive manner. DM #401 stated mice had been caught in parts of the building during the week of 10/20/25. DM #401 verified the presence of multiple flies and gnats in Resident #14's room and stated that housekeeping should be cleaning the rooms every day to help control them.Interview on 10/22/25 at 12:01 P.M. with the Administrator confirmed there had been a mouse problem in both Resident #14 and Resident #49's rooms. The Administrator revealed that traps were placed in both rooms, and they were sprayed with peppermint oil. The Administrator stated if the problem persisted, the facility would have the pest control vendor complete a more aggressive treatment. Review of the pest control service report dated 09/12/25 revealed a monthly standard service was completed. Further review revealed the outside was inspected and some of the bait stations (used to treat rodents) had bait eaten. The glue boards (non-toxic trays with a strong adhesive to trap and immobilize pests like mice, rats, and insects) were changed in the kitchen. Fly lights (used to attract flies and other insects) were treated, along with all the doors. There were drain flies in the kitchen, Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366328 If continuation sheet Page 6 of 7 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 10/27/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete and a treatment was completed. Additional review of the open actions from previous service section revealed on 12/13/24, door gaps were noted with a recommendation to add/repair door sweeps on the common area doors; on 01/10/25, a water leak was identified in the kitchen with a recommendation to repair the leak; on 01/10/25, debris was present in the kitchen, with a recommendation to clean the area; on 04/11/25, debris was present in the kitchen, with a recommendation to clean and sanitize the area; and on 08/15/25, overgrown vegetation was noted on the exterior of the building, with a recommendation to cut the vegetation for insect and rodent control. The customer (facility) was identified as the responsible party for the open actions.Review of a Commercial Services Agreement Addendum, dated 10/09/25, revealed the pest control vendor provided an estimate for additional services to treat rats and mice. The scope and nature of the work was rodent repellent service. The agreement was not signed by the facility.Review of the pest control service report dated 10/10/25 revealed a monthly standard service was completed. Further review revealed a pipe leak was observed, causing gnats. It was recommended that the pipe be repaired and the kitchen be cleaned. When inspecting the bait stations, a dead mouse was found in the one by the front door. Additional review of the open actions from the previous services section revealed on 12/13/24, door gaps were observed, and it was recommended to add/repair door sweeps and on 08/15/25, overgrown vegetation was recommended to be cut down on the exterior of the building to control insects and rodents. The customer (facility) was identified as the responsible party for the open actions.Review of the facility policy titled, Pest Control Program, dated 2025, revealed it was the policy of the facility to maintain and effective pest control program that eradicated and contained common household pests and rodents. Further review revealed appropriate chemicals were used to control pests but could be used safely inside the building without compromising residents' health. The facility would maintain a report system of issues that may arise between scheduled visits with the outside pest service and treat as indicated. The facility would utilize a variety of methods in controlling certain seasonal pests, such as flies. These would involve indoor and outdoor methods that were deemed appropriate by the outside pest service and state and federal regulations.This deficiency represents non-compliance investigated under Complaint Number 2630302 and 2636464. Event ID: Facility ID: 366328 If continuation sheet Page 7 of 7