Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff interview and review of policy and procedures, the facility failed to
ensure a splint device was implemented as recommended by occupation therapy. This affected one (#34)
out of one resident reviewed for limited range of motion. The facility census was 67.
Findings include:
Review of medical record for Resident #34 revealed an admission dated of 07/23/15 with diagnosis
including cerebral infarction, dysarthia, muscle weakness, pain in right hand, major depression, dysphagia,
hypertension, diabetes type two, heart failure and Lupus.
Review of Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored a
15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact.
Further review of the MDS revealed the resident required extensive assistance of one person for dressing
and had impaired functional limitation on one side of the body for the upper and lower extremities.
Review of Occupational Therapy (OT) Discharge summary dated [DATE] documented resident goal to have
right hand splint to improve positioning and allow for ease of hand hygiene. Upon discharge resident right
palm based splint was being worn at night with no complaints. She was discharged with the right hand
splint for functional maintenance program for splinting.
Review of physicians orders from 05/09/19 through 02/18/20 lacked any documentation of the splint device
being ordered to ensure proper implementation.
Review of comprehensive care plan from 05/09/19 through 02/18/20 lacked any care plan for Resident #34
right palm based splint device for implementation.
Review of nursing notes from 05/09/19 through 02/18/20 lacked any documentation related to Resident #34
use of the right palm based splint devices to ensure proper implementation.
On 02/18/20 at 10:26 A.M. an observation was made of Resident #34. During the observation her right
hand was noted to be contracted. A splint device was observed on the dresser and was not in place.
On 02/19/20 at 2:33 P.M. an observation was made of Resident #34. During the observation her right hand
was contracted and the splint device was noted to be on the dresser. The splint device was not in place.
(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 7
Event ID:
366125
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
366125
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Divine Rehabilitation and Nursing at Shane Hill
10731 State Route 118
Rockford, OH 45882
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 02/19/20 at 2:35 P.M. interview with State tested Nurses Aide (STNA) #306 verified Resident #34 right
hand is contracted. She also verified she has never seen a split in place and has not seen a schedule for
the device. During the interview STNA #306 went to the computer to check on a splint schedule and verified
Resident #34 did not have a order or plan in place for placing the splint on her right hand.
On 02/19/20 at 4:31 P.M. Director of Nursing (DON) verified the facility had no documented to ensure the
splint device was implemented as recommended per OT. She also verified the Resident #34 revealed to her
she hasn't worn it in approximately six months. The DON also verified she is not sure why it wasn't
implemented properly. She also verified the Resident #34 right hand has always been contracted since her
stroke and is no additional loss of mobility related to the splint device note being implemented.
Review of policy and procure for brace and splint program dated December 2018 documented the purpose
of the brace and splint device is to achieve the highest level of independence possible. Further review
documented if a resident has a splint device recommended by a specialized therapist the nurse will obtain
a physician order for the splint, create a care plan for proper implementation and use and documented in
the electronic medical record effective ness of care plan interventions and progress towards goals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366125
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
366125
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Divine Rehabilitation and Nursing at Shane Hill
10731 State Route 118
Rockford, OH 45882
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on medical record review, observation, staff and resident interview, review of the facility smoker list,
review of mobile cognitively impaired resident list and review of policy and procedures, the facility failed to
secure tobacco products were stored in a safe manner. The affected one (#17) out of five residents
identified as smokers. This had the potential to affect 27 mobile cognitively impaired residents (#1, #3, #4,
#6, #13, #18, #19, #21, #22, #23, #25, #27, #29, #30, #35, #36, #38, #45, #46, #48, #58, #62, #64, #67,
#70, #71 and #172) were mobile and cognitively impaired with high risk for accident hazards related
unsecured tobacco products. Facility census was 67.
Findings include:
Review of medical record for Resident #17 revealed an admission dated of 03/18/19 with diagnosis
including type two diabetes, anoxic brain injury, left lower below the knee amputee, hypertension and
vitamin D deficiency.
Review of guest who smoke list undated documented Resident #17 was a smoker.
On 02/18/20 at 11:28 A.M. an observation was made of Resident #17 room. During the observation he was
observed to have a tray with tobacco with empty filtered cigarettes to roll his own cigarettes. During the
observation Resident #17 revealed he was a smoker and always kept his tobacco in his room to roll his own
cigarettes.
On 02/18/20 at 4:21 P.M. an interview with the Director of Nursing (DON) verified Resident #17 is not
suppose to have his tobacco and tobacco products in his room. She then verified these items should be
kept secure at the nurses station. She also verified she would have it removed from the room and secure it
at the nurses station.
Review of mobile cognitively impaired resident list undated provided by the facility revealed residents (#1,
#3, #4, #6, #13, #18, #19, #21, #22, #23, #25, #27, #29, #30, #35, #36, #38, #45, #46, #48, #58, #62, #64,
#67, #70, #71 and #172) were mobile and cognitively impaired with high risk for accident hazards related
unsecured tobacco products. The facility confirmed the resident listed on this form could potentially access
unsecured smoking material.
Review of policy and procedure titled Resident Smokers Policy revised June 2016 documented all lighters,
matches, cigarettes, and tobacco must be kept secure at the nurses station. The policy is to provide and
maintain smoking practices to ensure the safety and comfort of all residents, staff and visitors.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366125
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
366125
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Divine Rehabilitation and Nursing at Shane Hill
10731 State Route 118
Rockford, OH 45882
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, staff interview and facility policy review, the facility failed to properly store Tuberculin
Purified Protein Derivative in two of the three medication storage rooms. Facility census was 67.
Findings include:
Observation on 02/19/20 at 9:25 A.M. of the medication storage in the memory care unit medication room
refrigerator revealed an opened vial of Tuberculin Purified Protein Derivative with no date of opening. The
box indicated once entered the vial should be discarded after 30 days.
Observation on 02/19/20 at 9:35 A.M. of the medication storage in the west nurses station medication room
refrigerator revealed an opened vial of Tuberculin Purified Protein Derivative with no date of opening. The
box indicated once entered the vial should be discarded after 30 days.
Interview on 02/19/20 at 9:25 A.M. with Assistant Director of Nursing #106 provided verification of lack of an
opened date on the bottle or the box of Tuberculin Purified Protein Derivative
Review of the facility policy titled Medication Management dated 10/19 revealed medications will be dated
per manufactures guidelines.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366125
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
366125
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Divine Rehabilitation and Nursing at Shane Hill
10731 State Route 118
Rockford, OH 45882
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 0791
Provide or obtain dental services for each resident.
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 and resident and staff interview, the facility failed to provide routine dental services
for a resident. This affected one (#11) of four sampled for dental care services. The facility census was 67.
Residents Affected - Few
Findings include:
Review of the clinical record revealed Resident #11 was admitted [DATE] with diagnoses of type-two
diabetes, hypertension, hyperlipidemia and hypothyroidism.
Review of the care plan dated 08/14/19 revealed Resident #11 was edentulous, had full dentures, and
preferred not but prefers not to wear them.
Review of physician note dated 05/09/2018 revealed Resident #11 was seen in facility by the facility
contracted dentist for routine oral exam. The findings stated the resident's dentures did not fit well, and the
next visit was recommended in 12 months.
Review of physician note dated 11/21/18 revealed Resident #11 was seen at the facility by the facility
contracted dentist for a focused exam regarding concerns with dentures. Suggested treatment included to
adjust as needed.
Review of Resident #11's annual Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 15
out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact.
Further review of the MDS revealed the resident had broken or loosely fitting full or partial dentures and
had no natural teeth or tooth fragment(s) (edentulous).
Interview conducted 02/18/20 at 10:47 A.M., Resident #11 revealed she did not wear her dentures due to
them not fitting properly. She further stated she had not seen a dentist in over a year.
Interview 02/19/20 at 2:30 P.M., Social Worker #153 verified Resident #11 had not received dental services
since 11/21/18.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366125
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
366125
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Divine Rehabilitation and Nursing at Shane Hill
10731 State Route 118
Rockford, OH 45882
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, review of pureed pork recipe, and review of facility list of residents on
pureed diets, the facility failed to prepare pureed food in a manner that retained its nutritive content. This
had the potential to affect eight residents (#14, #21, #26, #35, #54, #56, #63, and #68) on pureed diets.
Facility census was 67.
Residents Affected - Some
Findings include:
Observation 02/19/20 at 9:50 A.M., [NAME] #512 add on half quart of water to eight pork riblets to make
eight servings of pureed pork riblets.
Interview 02/19/20 at 9:50 A.M., [NAME] #512 stated she added water to the eight servings of meat until
the the consistency was like pudding.
Interview 02/19/20 at 9:55 A.M., Dietary Manager #150 verified she was unaware the pureed pork recipe
called for barbeque sauce not water for thinning meat consistency.
Review of policy titles Pureed Pork Riblet dated 2019 revealed barbeque sauce is to be added to the
pureed meat if the consistency needs to be thinned.
Review of facility list of residents on pureed diets revealed eight residents (#14, #21, #26, #35, #54, #56,
#63, and #68) in the facility received pureed diets.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366125
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
366125
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Divine Rehabilitation and Nursing at Shane Hill
10731 State Route 118
Rockford, OH 45882
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, review of policies and procedures, and review of list provided by
facility of residents who do not eat by mouth (NPO), the facility failed to prepare food in a sanitary manner.
This had the potential to affect all but two residents (#8 and #58) of 67 residents who received meals from
the kitchen. Facility census was 67.
Findings include:
Observation on 02/19/20 from 10:40 A.M. to 10: 50 A.M revealed [NAME] #512 stopped plating food to
write on resident dining tickets, reheat pureed food in the microwave, and flip through a binder on the
kitchen counter. [NAME] #512 began plating food again placing pickles on the plate with her gloved hands,
without removing her gloves and performing hand hygiene between tasks.
Interview 02/19/20 at 10:50 A.M. [NAME] #512 verified she did not change her gloves or perform hand
hygiene between tasks during.
Review of policy titled Disposable Gloves dated 04/10 revealed gloves are to be changed between tasks
and hands washed each time gloves are removed to prevent cross-contamination.
Review of facility list of NPO residents, Resident #8 and resident #58 are the only residents who did not
receive meals from the kitchen.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366125
If continuation sheet
Page 7 of 7
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F791 - Dental Services
Provide or obtain dental services for each resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F688 - Mobility
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.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the February 20, 2020 survey of DIVINE REHABILITATION AND NURSING AT SHANE HILL?
This was a inspection survey of DIVINE REHABILITATION AND NURSING AT SHANE HILL on February 20, 2020. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DIVINE REHABILITATION AND NURSING AT SHANE HILL on February 20, 2020?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.