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Deficiency Records for Divine Rehabilitation and Nursing at Toledo
A list of the most recent deficiencies for Divine Rehabilitation and Nursing at Toledo. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Divine Rehabilitation and Nursing at Toledo. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-02 | 2024-07-18 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-07-02 | 2024-07-18 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-07-02 | 2024-07-18 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-05-23 | 2024-07-18 | N |
| 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. | Health | 2024-05-23 | 2024-07-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide activities to meet all resident's needs. | Health | 2024-05-23 | 2024-07-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-05-23 | 2024-07-18 | N |
| 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. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-05-23 | 2024-07-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-05-23 | 2024-07-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-05-23 | 2024-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-23 | 2024-07-18 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-05-23 | 2024-07-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-23 | 2024-07-18 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-05-23 | 2024-07-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-23 | 2024-07-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-05-23 | 2024-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-23 | 2024-07-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| 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. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-20 | 2024-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-16 | 2024-04-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-16 | 2024-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-16 | 2024-04-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-16 | 2024-04-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-25 | 2024-04-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-25 | 2024-04-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-22 | 2024-03-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-22 | 2024-03-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-06 | 2023-09-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-06 | 2023-09-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-06 | 2023-09-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-06 | 2023-09-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-13 | 2023-06-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-18 | 2023-06-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-14 | 2023-04-20 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-22 | 2023-04-20 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-03-22 | 2023-04-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-14 | 2023-04-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-14 | 2023-04-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-14 | 2023-04-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-14 | 2023-04-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-14 | 2023-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-04-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-14 | 2023-04-20 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-12-27 | 2023-04-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-27 | 2023-04-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-13 | 2023-04-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-13 | 2022-11-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-13 | 2022-11-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-13 | 2022-11-07 | Y |
| Post nurse staffing information every day. | Health | 2022-10-13 | 2022-11-07 | Y |
| 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. | Health | 2022-09-28 | 2022-11-07 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-28 | 2022-11-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-28 | 2022-11-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-28 | 2022-11-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-28 | 2022-11-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-27 | 2022-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-27 | 2022-07-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-06 | 2022-05-20 | Y |
| Provide appropriate care/assistance for a resident with a prosthesis. | Health | 2022-04-06 | 2022-05-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-26 | 2021-11-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-10-26 | 2021-11-16 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-10-26 | 2021-11-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-10-26 | 2021-11-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-26 | 2021-11-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-26 | 2021-11-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-26 | 2021-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-26 | 2021-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-26 | 2021-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-26 | 2021-11-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-26 | 2021-11-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-26 | 2021-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-26 | 2021-11-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-26 | 2021-11-16 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-26 | 2021-11-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-11 | 2019-05-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-11 | 2019-05-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-11 | 2019-05-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-11 | 2019-05-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-11 | 2019-05-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-11 | 2019-05-21 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-04-11 | 2019-05-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-11 | 2019-05-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-04-11 | 2019-05-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-09 | 2019-05-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-09 | 2019-05-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-09 | 2019-05-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-09 | 2019-05-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-09 | 2019-05-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-09 | 2019-05-21 | N |
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