Inspection·December 23, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, review of hospital records, staff, pharmacist, and physician interview, and review of the facility policy, the facility failed to ensure residents were administered medications indicated for their medical diagnosis and free from unnecessary medications. This affected one (#39) of three residents reviewed for unnecessary medications. The facility census was 65.Findings include: Review of the medical record for Resident #39 revealed an admission date of 11/24/25 and a discharge date of 12/22/25. Admitting diagnosis included Type I diabetes mellitus (T1DM) (a form of diabetes known as juvenile diabetes where the pancreas does not function at all in the production of insulin to control blood sugar levels in the body).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and had a diagnosis of T1DM and required insulin injections.Review of the diagnosis list for Resident #39 revealed a diagnosis of Type I diabetes mellitus with other specified complications, Type I diabetes mellitus with diabetic autonomic (poly) neuropathy, chronic osteomyelitis, and acquired absence of right leg below the knee.Review of the hospital history and physical (H&P) (detailed history of the patient of past medical diagnosis and current problems during hospitalization) dated 11/13/25 revealed Resident #39 had a diagnosis of Type I diabetes mellitus.Review of the care plan, initiated 12/09/25, revealed Resident #39 had pain related to T1DM.Review of a written physician order dated 11/26/25 revealed Resident #39 was ordered Trulicity (a once weekly injectable medication used for Type II diabetes [T2DM]) 0.75 milligrams (mg) subcutaneously weekly. Further review of the physician orders located in the electronic medical record (EMR) revealed Resident #39 had an order dated 11/27/25 for Trulicity subcutaneous solution auto-injector 0.75 mg subcutaneously in the morning every Monday for diabetes, give 0.75 mg weekly. Additionally, Resident #39 was ordered Lantus SoloStar (long-acting insulin) subcutaneous solution pen-injector 100 unit/milliliter (u/ml), inject 32 units subcutaneously two times a day for diabetes and insulin lispro (rapid-acting insulin) subcutaneous solution pen-injector 100 u/ml, inject subcutaneously before meals and at bedtime for diabetes. Review of the Medication Administration Record (MAR) for December 2025 revealed Resident #39 was administered doses of Trulicity on 12/01/25, 12/08/25, and 12/15/25.Interview on 12/22/25 at 2:41 P.M. with Pharmacist #550 revealed Trulicity was not an approved medication for use in a patient with T1DM. Pharmacist #550 stated Trulicity was only approved for use in people who produced insulin as it triggered a hormone in the body to trigger insulin to work and do the job it was supposed to do. Pharmacist #550 further stated that anyone with a diagnosis of T1DM did not make insulin so Trulicity was useless for someone with T1DM and would be considered an ineffective treatment, and an unnecessary medication for that population of people.Interview on 12/22/25 at 3:00 P.M. with Nurse Practitioner (NP) #515 verified she prescribed Trulicity to Resident #39. NP #515 further stated she would use Trulicity to treat a resident with a diagnosis of T1DM and further stated she treated T1DM and T2DM the same. NP #515 verified she would give Trulicity to a resident with T1DM and Residents Affected - Few (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 2 Event ID: 366328 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 12/23/2025 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)