19 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Toledo, OH
2-star overall rating with 1-star inspections with $21,598 in total fines with 19 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
4420 South Avenue, Toledo, OH
(419) 531-4201
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
75
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Divine Healthcare Management
Operator or chain grouping
Approved since
1980-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.35
Registered nurse staffing
LPN hours / resident day
1.23
Licensed practical nurse staffing
Aide hours / resident day
1.82
Nurse aide staffing
Weekend hours
3.04
Weekend nurse staffing
RN turnover
78%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
92.4%
6.7 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.7% |
94.5%
6.8 pts worse
|
95.5%
7.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 79.5% |
26.1%
53.4 pts worse
|
11.4%
68.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 12.5% |
6.2%
6.3 pts worse
|
5.4%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
25.4%
7.1 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
11.5%
2.8 pts worse
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.4% |
7.7%
0.3 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
6.2%
3.5 pts worse
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
21.7%
2.3 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
3.7%
3.8 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
78.1%
12.8 pts better
|
81.7%
9.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.8% |
75.6%
8.2 pts better
|
79.7%
4.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-09-12
Fire Safety
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.
Corrected 2024-09-12
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-12
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-12
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-12
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-09-12
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-12
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-12
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-12
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-31
Fire Safety
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.
Corrected 2022-08-31
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-08-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-31
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-31
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-31
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-08-31
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-31
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-09-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-09-20
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-09-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-09-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-09-20
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-09-20
Inspection history
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-08
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-10-08
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-08-30
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-14
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-08-14
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-14
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-12
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-12
Health
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.
Corrected 2024-09-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-12
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-12
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-12
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-12
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-09-12
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-12
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-09-12
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-07
Health
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.
Corrected 2023-06-07
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-08-31
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-08-31
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2022-08-31
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-08-31
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-08-31
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-31
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-31
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-31
Health
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.
Corrected 2022-08-31
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-31
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-31
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-08-31
Health
Post nurse staffing information every day.
Corrected 2022-08-31
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-08-31
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-08-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-09-20
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-09-20
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-09-20
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-09-20
Health
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.
Corrected 2019-09-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-09-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-09-20
Health
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.
Corrected 2019-09-20
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-09-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-09-20
Health
Respond appropriately to all alleged violations.
Corrected 2019-09-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-20
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-09-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-09-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-09-20
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-09-20
Health
Provide appropriate foot care.
Corrected 2019-09-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-09-20
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-09-20
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-09-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-09-20
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-20
Penalties and ownership
Fine · fine $21,598
Fine
Payment Denial · denial start 2023-05-20 · 18 days
18 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Officer · Individual
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