Inspection·December 1, 2025

F 0550 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was on the phone per video at the time of the incident, knew what they were talking about, at which time RN #590 came up behind Resident #145 and poked the resident in the right arm with the vaccination. Interview with the Administrator on 11/24/25 at 12:22 P.M. verified RN #590 administered the influenza vaccination to Resident #145 against her will and also verified the medication error occurred when RN #590 administered the influenza vaccination, instead of the pneumococcal vaccination. The Administrator confirmed Resident #145 received two influenza immunizations this season and should not have. Interview with Resident #145 on 12/01/25 at 11:50 P.M. revealed she decided to receive the influenza vaccination in October 2025, and it was administered. Resident #145 voiced concern that the influenza vaccination was administered again and against her will in November 2025. Resident #145 stated on 11/12/25 RN #590 entered her room and informed her she was to receive an influenza vaccination. Resident #145 stated she verbally refused the immunization and informed RN #590 that she previously received the vaccination. RN #590 told Resident #145 that she did not know what she was talking about at which time RN #590 came up behind Resident #145 and injected the immunization into her right arm. Resident #145 said she reported the nurse to administration. Resident #145 stated she is now afraid of RN #590, while the nurse no longer provides her care she is still in the building and provides care to other residents. Resident #145 also voiced concerns for her health due to receiving two influenza vaccinations a month apart. Interview with Certified Nurse Practitioner (CNP) #600 on 12/01/25 at 12:02 P.M. revealed she was aware Resident #145 received two influenza vaccinations. CNP #600 did see Resident #145 after being made aware of the administration of a second influenza vaccination and had no health concerns. Review of the undated facility policy titled General Immunization/Vaccination revealed residents, staff members, and volunteer workers retain the right to refuse immunizations. Review of the undated facility policy titled Medication Administration stated medications are to be administered as ordered by the physician and in accordance with professional standards of practice. Review of the undated facility policy titled Abuse, Neglect, and Exploitation revealed abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. This deficiency represents non-compliance investigated under Complaint Numbers 2676384 and 2670000. Event ID: Facility ID: 366328 If continuation sheet Page 2 of 5 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 12/01/2025 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 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on medical record review, staff interviews, review of the facility incident investigation, review of video surveillance, review of employee personnel files, review of the facility self-reported incident (SRI), and review of facility policy, the facility failed to ensure residents were free from abuse. Actual harm occurred on 11/15/25 at 8:42 P.M. when Resident #169 was subjected to excessive physical force by a facility staff member, after which Resident #169 verbalized a fear for his safety, and being depressed at times with positive thoughts of self-harm. This affected one (#169) of three residents reviewed for abuse. The facility census was 67.Review of the medical record for Resident #169 revealed an admission date of 07/22/25 and discharged date of 11/19/25. Diagnoses included alcohol dependence with withdrawal, anxiety, depression, difficulty walking, tobacco use, type two diabetes mellitus, chronic obstructive pulmonary disease, and noncompliance with other medical treatment.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #169 revealed he was identified as moderately cognitively impaired. Resident #169 was independently mobile with a manual wheelchair and required minimal assistance with bathing, lower body dressing, bed mobility, and transfers, had no aggressive behaviors toward self or others and no refusals of care.Review of a progress note dated 11/15/25 and timed at 8:58 P.M. written by Licensed Practical Nurse (LPN) #800 revealed Resident #169 was observed drinking alcohol in the designated smoking area. When Resident #169 was approached regarding the liquor and beer, the resident became agitated and started swinging at staff threatening them. Review of the physician orders for Resident #169 revealed he did not have an order to consume alcohol.Review of progress notes dated 11/16/25 revealed Resident #169 refused nursing care offered at 12:02 A.M., medications offered at 8:00 A.M., and a post-incident skin assessment attempted at 2:02 P.M.Review of a psychiatric physician note dated 11/17/25 revealed Resident #169 reported an altercation with LPN #800 to the physician. Resident #169 reported feeling depressed at times with positive thoughts of self-harm.Review of a progress note dated 11/17/25 and timed at 8:10 P.M. revealed Resident #169 was placed on a one-to-one observational status. Review on 11/25/25 at 10:45 A.M. and on 12/01/25 at 9:45 A.M. with the Administrator, of a two-minute surveillance video dated 11/15/25 and timestamped at 8:42 P.M. revealed Resident #169 was in the outdoor smoking area with a group of other residents. Resident #169 was observed sitting in his wheelchair wearing an unzipped coat and smoking a cigarette. Resident #169 was holding his cigarette with his right hand. Certified Nurse Assistant (CNA) #605 and CNA #712 were supervising the group of residents in the outdoor smoking area. LPN #800 entered the smoking area and walked toward Resident #169, approached the front of Resident #169, then circled around the resident from the right side, and stopped on the left side of the resident. LPN #800 then reached toward Resident #169 with her right hand, taking hold of the front left side of Resident #169's coat. LPN #800 proceeded to pull open the coat toward the left side of Resident #169's body and with her left hand reached between the coat and Resident #169's left side. Unidentifiable items were seen falling to the ground. Resident #169 pushed at LPN #800 with his left arm and LPN #800 let go of the coat. LPN #800 again reached for Resident #169's coat, this time while holding Resident #169's left arm down, LPN #800 pulled open the coat to the residents' left side and reached inside the coat toward Resident #169's left side. CNA #605 was seen walking toward the resident's right side while LPN #800 was reaching in and around Resident #169's coat and pulling on Resident #169's left arm. LPN #800 let go of Resident #169's left arm and backed away from the resident. Resident #169 was then observed shaking his left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366328 If continuation sheet Page 3 of 5 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 12/01/2025 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 - Actual harm Residents Affected - Few arm at LPN #800 while shuffling his feet to move the wheelchair closer to the nurse. LPN #800 took hold of Resident #169's left arm and pulled it away from his body while CNA #605 flicked the cigarette out of Resident #169's right hand onto the ground. LPN #800 moved to Resident #169's right side, took hold of the right side of the coat, pulled it open, reached into the coat toward Resident #169's right side and obtained an open can of an alcoholic beverage. LPN #800 handed the open beverage can to CNA #605 who poured the liquid out in the grassy area behind Resident #169. Resident #169 extended his right arm and index finger toward LPN #800's face. LPN #800 swung at Resident #169's right arm, making contact, knocking Resident #169's arm down. This occurred two additional times before LPN #800 walked away, leaving the outdoor smoking area.Review of the facility investigation interviews dated 11/16/25 with CNA #605 and CNA #712 revealed no deviation in the description of events between Resident #169 and LPN #800 as observed in the video surveillance. CNA #605's statement revealed concerns for safety as Resident #169 was threatening to burn the nurse with his cigarette. CNA #605 found it necessary to remove the cigarette from Resident #169's hand during the incident. Review of a statement provided by the Director of Nursing (DON) on 11/17/25 revealed Resident #169 indicated to her on 11/17/25 that he did not feel safe in the facility. The DON offered a continuous one-to-one and Resident #169 agreed.Review of the facility self-reported incident (SRI) #267611 filed on 11/16/25 at 12:25 P.M. revealed Resident #169 was abused by LPN #800 on 11/15/25 at 8:42 P.M. Continued review of the SRI revealed Resident #169 sustained mental anguish, fear, and a feeling of being unsafe.Interview on 11/25/25 at 10:45 A.M. with the Administrator revealed items that fell to the ground from Resident #169's coat during the altercation with LPN #800 on 11/15/25 were a small bottle of fireball whiskey, a pack of cigarettes, and a bottle of unidentified pills. Continued interview revealed Resident #169 was noted to frequently obtain alcohol and illicit drugs while off facility property. The Administrator shared Resident #169 was placed on a one-to-one observational status due to Resident #169 being non-compliant and voicing he felt unsafe in the facility.Additional interview on 11/25/25 at 2:18 P.M. with the Administrator revealed the facility did not have a policy regarding alcohol consumption and a physician order was required for residents to consume alcohol while on the premises. The Administrator revealed there were no residents currently with physician orders allowing the consumption of alcohol.Concurrent interviews on 11/25/25 at 3:15 P.M. with LPN #530 and LPN #542 revealed Resident #169 would often consume alcohol on the premises and did not have a physician order to do so. Review of the disciplinary action interview with LPN #800 dated 11/19/25 revealed LPN #800 contacted the on-call supervising nurse when she learned Resident #169 was consuming alcohol in the smoking area. LPN #800 was told by the on-call nurse, LPN #801, to confiscate the alcohol.Review of the personnel file for LPN #800 revealed she was hired on 02/27/25 and terminated on 11/19/25. LPN #800 was trained on abuse, per facility policy, on 02/27/25. Review of a disciplinary action dated 11/19/25 revealed LPN #800 was terminated as a direct result of the altercation on 11/15/25 with Resident #169.Review of a disciplinary action dated 11/19/25 for LPN #801 revealed she was also terminated for advising LPN #800 to confiscate the open container of alcohol from Resident #169 and for failing to timely report the incident to the Administrator.Review of the undated facility policy titled Abuse, Neglect, and Exploitation revealed abuse included punishment with the result of mental anguish, and mistreatment included inappropriate treatment of a resident. Further review of this policy revealed the facility would implement policies and procedures to prevent and prohibit abuse. The deficiency was corrected on 11/21/25 at 3:32 P.M. when the facility implemented the following corrective actions:- On 11/16/25, the incident between Resident #169 and LPN #800 was reported to the Administrator by Human Resources Director #606 immediately after Resident #145 reported the incident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366328 If continuation sheet Page 4 of 5 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 12/01/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the Human Resources Director. - On 11/16/25, the Administrator notified the Medical Director of the incident between LPN #800 and Resident #169.- On 11/16/25 at 12:25 P.M., the Administrator reported the incident to the state agency. (SRI #267611).- On 11/16/25, the DON assessed Resident #169 with no injuries noted.- On 11/16/25, the DON/designee conducted resident interviews for all interviewable residents to ensure they felt safe in the facility. Interviews revealed no other concerns about safety.- On 11/16/25, the DON/designee conducted skin assessments on all non-interviewable residents with no negative findings.- On 11/16/25, the Administrator reviewed the two-minute video footage of the incident dated 11/15/25 and timed at 8:22 P.M.- On 11/16/25, the Administrator interviewed Residents #138 and #145 who were sitting near Resident #169 in the video.- On 11/16/25, the Administrator completed staff interviews with CNA #605, CNA #712, LPN #572, LPN #800, and LPN #801.- On 11/16/25, the Administrator suspended LPN #800 and LPN #801.- On 11/17/25, Resident #169 was evaluated by psychiatry.- On 11/17/25, the DON touched base with Resident #169 and the resident indicated he did not feel safe in the facility. The DON offered a continuous one-to-one with an aide and Resident #169 agreed. An aide was placed to directly observe Resident #169.- On 11/17/25, Resident #169 was assessed by Social Services #554 with no additional concerns identified. Resident #169 was notified of the level of care paperwork being finalized for the transfer to another facility. Resident #169 had been accepted at another facility prior to the incident.- On 11/17/25, all staff were educated by Staff Development Coordinator #507 on abuse, neglect, exploitation, and timely reporting abuse.- On 11/17/25, the MDS Coordinator reviewed and updated Resident #169's care plan to reflect the trauma related to physical abuse.- On 11/17/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the incident and the action plan.- On 11/18/25, a police report was filed by the Administrator.- On 11/18/25, Resident #169 remained on direct observation.- On 11/18/25, Resident #169 was accepted to be admitted to another facility. Social Services #554 notified Resident #169 and made transportation arrangements. - On 11/19/25, all staff were educated on resident rights and smoking regulations by Staff Development Coordinator #507.On 11/19/25, the Administrator terminated LPN #801 and LPN #800 for violation of company policy.- On 11/19/25, Resident #169 remained on direct observation.- On 11/19/25 at 1:30 P.M., Resident #169 was discharged from the facility. Resident #169 was in his electronic wheelchair and had all personal items.- On 11/20/25, a monthly QAPI meeting was held with a review of the incident and actions taken presented.- On 11/21/25 at 3:32 P.M., the Administrator closed the SRI. This deficiency represents non-compliance investigated under Complaint Numbers 2660931 and 2670000. Event ID: Facility ID: 366328 If continuation sheet Page 5 of 5