Health inspection·April 27, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and family and staff interview, the facility failed to conduct a quarterly care plan review meeting. This affected one (#37) of 16 residents reviewed for care planning meetings. The facility census was 58. Findings include: Review of the medical record for Resident #37 revealed an admission date of 10/12/22 with medical diagnoses of dementia with other behavioral disturbances, diabetes mellitus, hypertension, depression, and hyperlipidemia. Review of the medical record for Resident #37 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #37 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, and toileting, and was dependent for bathing. Review of the medical record for Resident #37 revealed a progress note, dated 11/16/22 at 1:07 P.M., which revealed a care conference was held with staff and family. Review of the medical record for Resident #37 did not contain documentation to support the facility conducted a care plan review meeting since 11/16/22. Interview on 04/24/23 at 2:46 P.M. with Resident #37's daughter stated the family and resident representative have not been invited to a care plan review meeting for Resident #37 since the fall of 2022. Interview on 04/26/23 at 12:05 P.M. with Administrator confirmed the facility had not conducted a care plan review meeting for Resident #37 since the meeting on 11/16/22 or after the most recent quarterly assessment dated [DATE]. Administrator stated the facility did not have a care plan review meeting or care conference policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 2 of 8 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 04/27/2023 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to provide adequate interventions and supervision to ensure a cognitively impaired resident did not elope from the facility. Additionally, the facility failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to prevent further elopements. This affected one (#37) resident of seven residents reviewed on the secured memory care unit. The facility census was 58. Findings include: Review of the medical record for Resident #37 revealed an admission date of 10/12/22 with medical diagnoses of dementia with other behavioral disturbances, diabetes mellitus, hypertension, depression, and hyperlipidemia. Review of the medical record revealed Resident #37 was admitted to a room on the facility's secured memory care unit (MCU). Review of the medical record for Resident #37 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #37 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing toileting, and supervision with ambulation. The MDS did not have documentation to support Resident #37 had any behaviors or was wandering. Review of the medical record for Resident #37 revealed a care plan, dated 10/20/22, which revealed the resident was an elopement risk and wanderer related to history of leaving previous facility where he lived. The goal for the care plan indicated Resident #37 would not leave the facility unattended. Review of the elopement risk and wanderer care plan revealed all interventions were added to the care plan on 10/20/22 and included to provide activities, toileting, and to offer pleasant distractions. Further review of the care plans revealed an impaired cognition related to dementia care plan dated 10/21/22. The care plan had an intervention which indicated Resident #37 was to reside on the secured MCU. Review of the medical record for Resident #37 revealed a wandering scale risk assessment, dated 10/12/22, which revealed Resident #37 was at high risk for wandering. Review of the medical record for Resident #37 revealed an elopement risk assessment, completed 11/09/22, which revealed Resident #37 was at risk for elopement. Further review of the medical record revealed an elopement risk assessment, completed 01/19/23, revealed Resident #37 was not at risk for elopement. Review of the medical record for Resident #37 revealed a nursing note dated 11/09/22 at 6:08 A.M. which revealed the [NAME] hall unit nurse observed Resident #37 outside of the facility when she looking through another resident's window. The nursing note further revealed the [NAME] hall unit nurse went into the parking lot and brought Resident #37 back inside the facility. The nursing note revealed Resident #37's representative and nurse practitioner were notified of the elopement and the staff placed a WanderGuard (an electronic device used to prevent independently mobile and cognitively impaired residents from elopement) to Resident #37's left ankle. Observation on 04/26/23 from 7:18 A.M. to 7:30 A.M. of Resident #37 revealed Resident #37 wandered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 3 of 8 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 04/27/2023 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 - Few the halls of the MCU. Resident #37 was observed to push on the secured doors in MCU that go to the [NAME] hall unit. The doors alarmed and Resident #37 moved away from the doors. Staff were observed to walk into the hallway to check the alarming doors. Interview on 04/26/23 at 10:42 A.M. with Director of Nursing (DON) confirmed Resident #37 was found outside of the facility on 11/09/22 at 5:35 A.M. DON stated Resident #37 exited the MCU through a secured door on the MCU that opened to the outside. DON stated the secured exit door had an alarm that sounds for 15 seconds when staff or residents push on the door prior to the door opening. DON stated Resident #37 did not have any injuries from the incident. DON confirmed the Resident #37 wandered on the MCU and exit seeks at times. DON confirmed no resident-specific interventions were put in place after Resident #37's elopement on 11/09/22 or that the facility conducted a thorough investigation including root cause analysis. DON stated staff education and training was not completed after Resident #37's elopement on 11/09/22. Review of the facility policy titled, Elopement and Wandering Residents, dated 01/03/2020, stated the facility would ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and resident care in accordance with their person-centered care plan addressing the unique factors contributing to wandering or elopement risk. The policy stated alarms are not a replacement for necessary supervision and staff are to be vigilant in responding to alarms in a timely manner. The policy continued to state the facility staff would implement interventions to reduce hazards and risks and modify interventions when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 4 of 8 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 04/27/2023 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 0880 Provide and implement an infection prevention and control program. 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, observation, staff interview, and review of facility policies, the facility staff failed to maintain contact precautions during wound care, and failed to have a Legionella water management program in place. This directly affected one (#165) of three residents reviewed for transmission based precautions and had the potential to affect all 58 residents residing in the facility. The census was 58. Residents Affected - Many Findings include: 1. Review of Resident #165's medical record revealed an admission dated of 12/22/22. Diagnoses included type two diabetes mellitus, right lower cellulitis, chronic foot ulcer, venous insufficiency, morbid obesity, methicillin-resistant staphylococcus aureus (MRSA), anxiety, and hallucinations. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #165 was assessed as cognitively intact. Review of physician orders revealed an order dated 01/16/23 for contact isolation related to (MRSA) in a right foot wound. Review of wound care physician office notes dated 03/01/23 revealed Resident #165's right foot wound was recently cultured and was still positive for MRSA. Observation of wound care for Resident #165 on 04/26/23 at 12:50 P.M. revealed Licensed Practical Nurse (LPN) #208 entered Resident #165's room and prepared wound care items. A sign posted on Resident #165's door frame read to, See nurse before entering. Further observation revealed personal protective equipment (PPE), including gowns, were hanging on the back of a closet door in the room. LPN #208 did not put on a gown. LPN #208 proceeded to provide wound care to Resident #165's right foot. LPN #208 helped reposition Resident #165's legs in bed and elevated his legs on pillows. LPN #165 then removed the old wound dressing and applied a new dressing. LPN #208 did not put on a gown at any time during Resident #165's wound care. During an interview on 04/26/23 at 1:07 P.M., LPN #208 confirmed Resident #165 was ordered to be on contact precautions for MRSA in his right foot. LPN #208 confirmed she did not put on a gown while providing wound care to Resident #165's right foot. Review of the facility's policy dated 12/01/20 revealed contact precaution refers to actions designed to reduce/prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. Healthcare personnel caring for residents in contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 2. Interview with Maintenance Director #254 on 04/26/23 at 11:50 A.M. stated he did not have proof of the facility assessment or surveillance plan for Legionella, and he was not able to find a program on his electronic maintenance system to follow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 5 of 8 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 04/27/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Administrator on 04/26/23 at 11:56 A.M. verified there was no evidence of a facility assessment or surveillance plan for Legionella, and the facility did not have any knowledge it was not being completed. Review of the facility policy dated 12/01/22 revealed it is the the policy to establish primary and secondary strategies for the prevention and control of Legionella infections. The guidelines included Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. Event ID: Facility ID: 366125 If continuation sheet Page 6 of 8 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 04/27/2023 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of employee files, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNAs) who worked the in the facility for more than one year received 12 hours of continuing education for the previous year, and failed to ensure STNAs received specific education related to providing care and services to residents on the special care unit. This affected eight (STNA #212, #213, #218, #226, #243, #244, #246, and #278) of eight employee files reviewed. The deficient practice had the potential to affect all 58 residents residing in the facility. The census was 58. Findings include: 1. Review of STNA #212's employee file revealed a hire date of 05/18/08. The file indicated STNA #212 received only two hours of continuing education for the past year. The file was absent for any documentation STNA #212 completed any special training for the special care unit. 2. Review of STNA #213's employee file revealed a hire date of 09/19/96. The file indicated STNA #213 received only three hours of continuing education for the past year. The file was absent for any documentation STNA #213 completed any special training for the special care unit. 3. Review of STNA #218's employee file revealed a hire date of 04/21/23. The file was absent for any documentation STNA #218 completed any special training for the special care unit. 4. Review of STNA #226's employee file revealed a hire date of 09/11/03. The file indicated STNA #226 received only five hours of continuing education for the past year. The file was absent for any documentation STNA #226 completed any special training for the special care unit. 5. Review of STNA #243's employee file revealed a hire date of 02/20/23. The file was absent for any documentation STNA #243 completed any special training for the special care unit. 6. Review of STNA #244's employee file revealed a hire date of 01/22/19. The file indicated STNA #244 received only seven hours of continuing education for the past year. The file was absent for any documentation STNA #244 completed any special training for the special care unit. 7. Review of STNA #246's employee file revealed a hire date of 12/01/22. The file was absent for any documentation STNA #246 completed any special training for the special care unit. 8. Review of STNA #278's employee file revealed a hire date of 01/01/23. The file was absent for any documentation STNA #278 completed any special training for the special care unit. Interview on 04/25/23 at 5:30 P.M. with Director of Nursing verified four (#212, #213, #226, and #244) STNAs did not receive the required 12 hours of continuing education for the past year, and eight (#212, #213, #218, #226, #243, #244, #246, and #278) STNAs did not receive specialty care education. The facility identified 23 (#01, #06, #09, #14, #24, #27, #28, #30, #34, #35, #37, #39, #40, #41, #42, #48, #50, #52, #53, #56, #58, #60, and #61) residents who resided on the special care unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 7 of 8 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 04/27/2023 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 0947 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Dementia Care, dated 12/01/20, revealed all staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366125 If continuation sheet Page 8 of 8