Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Divine Rehabilitation And Nursing At Shane Hill during CMS and state inspections, most recent first.
A resident with dementia and intact cognition was subjected to neglect and abuse when a CNA placed an incontinence product on her to avoid frequent toileting, despite her ability to request assistance. After the resident fell, an LPN instructed staff to move her without assessment and attempted to silence her by placing a hand over her mouth. The incident was not immediately reported due to a CNA's fear of retribution, and the involved staff later admitted to the actions during the facility's investigation.
A resident with dementia and intact cognition, who required assistance for mobility and toileting, was subjected to inappropriate care when a CNA placed an incontinence product on her instead of assisting her to the bathroom, and an LPN failed to assess her after a fall and attempted to quiet her by placing a hand over her mouth. The incident was not reported to the Administrator in a timely manner due to a CNA's fear of retribution, resulting in a delay in investigation and substantiation of abuse and neglect.
A facility failed to immediately remove a CNA from the floor following allegations of verbal abuse towards a resident. The incident involved a verbal altercation where the CNA raised her voice at a cognitively intact resident. Despite the facility's policy requiring immediate action to protect residents, the CNA continued to work for two hours after the incident began. The delay in removal was confirmed by the DON and Administrator.
A resident with severe cognitive impairment was affected by the misappropriation of Oxycodone by an agency nurse. The nurse removed 19 doses from the medication cart, but only four were documented as administered. Surveillance footage did not show the nurse medicating the resident, and staff interviews revealed no unusual behaviors from the resident. The facility's investigation confirmed the misappropriation, and the incident was reported to authorities.
A resident with dementia accessed a staff member's coat in a common area, taking a lighter and cigarette. Staff retrieved the lighter but needed the resident's family to deescalate the situation and retrieve the cigarette. The incident occurred because staff's personal items were not secured due to ongoing construction in the nursing office.
The facility failed to ensure a resident authorization form was in place for a resident with a personal fund account. The resident, with multiple medical diagnoses and moderate cognitive impairment, had no documentation supporting that they or their representative had signed an authorization form. This was confirmed by the Business Office Manager, contrary to the facility's policy requiring written authorization for managing resident personal funds.
A resident with multiple diagnoses, including dementia and chronic pain syndrome, reported damaged drywall and a dripping faucet in their room. Observations confirmed these issues, and the Maintenance Director was unaware of them, indicating a lack of communication and oversight in maintaining the resident's living conditions.
A resident with multiple diagnoses, including a fracture and diabetes, developed new pressure ulcers due to improper application of medical devices. The resident's care plan was not followed correctly, leading to decreased circulation and the development of stage two pressure injuries. Staff interviews and observations confirmed the improper application of splints and dressings, resulting in avoidable pressure ulcers.
The facility failed to ensure a resident's BiPap machine was administered as ordered. Despite a physician's order and the arrival of a new mask, the BiPap was not used from 03/25/24 to 04/02/24 due to a broken mask and subsequent delays.
A facility failed to monitor blood pressure before administering medications to a resident with hypertension, despite physician orders to hold the medications if systolic blood pressure was less than 110 mm/Hg. An LPN administered the medications without obtaining the required vital signs, which was confirmed immediately after the administration.
The facility failed to ensure insulin pen needles were primed after a new needle was applied, affecting a resident with diabetes mellitus type II. An LPN injected the resident without priming the needle, contrary to the manufacturer's instructions.
The facility failed to ensure proper use of PPE and hand hygiene during procedures for a resident with multiple medical conditions, and did not maintain a sanitary environment during meal service. These deficiencies were identified through staff interviews, observations, and policy reviews.
Failure to Protect Resident from Abuse and Neglect by Staff
Penalty
Summary
A deficiency occurred when a resident with dementia and intact cognition, who was independent with eating and able to use the call light for toileting assistance, was subjected to neglect and abuse by facility staff. The resident was found yelling and lying beside her bed after a fall, with no immediate documentation or assessment of the incident. A CNA reported that another CNA placed an incontinence product on the resident, despite her ability to request toileting assistance, to avoid frequent toileting. The same CNA informed the resident she would be checked and changed later, disregarding the resident's actual needs and preferences. Following the fall, the LPN instructed two CNAs to assist the resident back to bed without performing an assessment or taking vital signs. During the transfer, when the resident began to yell, the LPN placed her hand over the resident's mouth and asked her to be quiet. The CNA who witnessed these actions delayed reporting the incident due to previous negative experiences with reporting at another facility and fear of retribution. The incident only came to management's attention when the CNA later explained her reasons for not wanting to continue working at the facility. The facility's investigation confirmed that the LPN and CNA involved in the incident admitted to the actions described, including failing to assess the resident after a fall, placing an incontinence product on the resident unnecessarily, and attempting to silence the resident by placing a hand over her mouth. These actions were in direct violation of the facility's abuse and neglect policy, which requires prompt reporting and protection of residents' rights and well-being.
Failure to Timely Report and Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that allegations of abuse and neglect were reported in a timely manner to the Administrator, as required by policy. A resident with dementia and other medical conditions, who was cognitively intact and required assistance for mobility and toileting, was involved in an incident where she was found yelling and lying beside her bed. Documentation of the incident was incomplete, and there was no immediate follow-up recorded regarding the circumstances of her fall or her condition after the event. A Certified Nursing Assistant (CNA) reported that another CNA placed an incontinence product on the resident and instructed her to urinate in it, rather than assisting her to the bathroom, despite the resident's ability to use the call light and ambulate with assistance. Later, when the resident was found on the floor, a Licensed Practical Nurse (LPN) instructed the CNAs to return the resident to bed without assessing her and placed a hand over the resident's mouth to quiet her when she yelled. The CNA who witnessed these actions did not immediately report the incident to management due to previous negative experiences with reporting at another facility and fear of retribution. The incident was only brought to management's attention several days later, after the CNA informed the scheduler of her concerns and reluctance to continue working at the facility. An investigation was then initiated, and it was substantiated that the LPN did not assess the resident after her fall and that inappropriate actions were taken by both the CNA and LPN. The delay in reporting the incident to the Administrator and the lack of immediate investigation constituted the deficiency.
Failure to Immediately Remove Staff After Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure immediate removal of staff from the floor following allegations of verbal abuse towards a resident. The incident involved a Certified Nursing Assistant (CNA) who was reported to have been argumentative and raised her voice at a resident. The situation began when the resident, who was cognitively intact and required supervision for certain activities, was reportedly cussing and yelling at the CNA. The CNA responded by raising her voice and arguing with the resident, which was observed by other staff members. Despite the altercation, the CNA was not immediately removed from the floor and continued to work for approximately two hours after the incident began. The facility's policy on abuse, neglect, and exploitation requires immediate action to protect residents from harm and further abuse during investigations. However, in this case, the CNA was allowed to remain in the facility until the Director of Nursing (DON) was informed of the situation and instructed the CNA to leave. The delay in removing the CNA from the floor was confirmed by interviews with the DON and the Administrator, who acknowledged that the CNA remained in the facility for two hours after the initial altercation. This failure to act promptly is a deficiency in the facility's response to allegations of abuse.
Misappropriation of Medication by Agency Nurse
Penalty
Summary
The facility failed to protect a resident from the misappropriation of medication, specifically Oxycodone, by an agency nurse. The resident, who was severely cognitively impaired and diagnosed with conditions such as Alzheimer's disease and dementia, had a physician's order for Oxycodone to manage severe pain. However, discrepancies were found between the medication administration record (MAR) and the controlled substance record (CSR), indicating that 15 doses of Oxycodone were removed from the medication cart but not documented as administered to the resident over two days. An investigation revealed that an agency nurse, RN #100, was responsible for administering 19 doses of Oxycodone, but only four doses were recorded on the MAR as given to the resident. Surveillance footage did not show the nurse administering the medication to the resident, and attempts to contact the nurse were unsuccessful. Staff interviews indicated that the resident did not exhibit any unusual behaviors during this period, and no staff members reported witnessing the nurse administering the medication. Further investigation by the facility confirmed the misappropriation of medication by RN #100. The nurse was described as disorganized and unfocused during shift reports, and there were inconsistencies in her accounts of the resident's behavior. The facility's investigation substantiated the allegation of misappropriation, and the incident was reported to relevant authorities, including the Ohio Board of Nursing and the local sheriff's office.
Failure to Prevent Resident Access to Hazardous Items
Penalty
Summary
The facility failed to ensure residents were free of potential hazards and accidents, specifically affecting a resident with dementia and severe psychotic disturbances. The resident, who had impaired cognition and required supervision for activities of daily living, managed to access a staff member's coat that was hanging in a common area. The resident took a lighter and a cigarette from the coat. While staff were able to retrieve the lighter, they were unsuccessful in retrieving the cigarette, necessitating the intervention of the resident's family to deescalate the situation. The incident occurred because the staff's personal items, which are normally locked in the nursing office, were left in a common area due to ongoing construction in the nursing office. This oversight created a potential hazard for the resident and other cognitively impaired and independently mobile residents in the memory unit. The facility's failure to secure personal items in a safe location led to the resident accessing potentially dangerous items, highlighting a lapse in supervision and safety protocols.
Failure to Obtain Authorization for Resident Personal Fund Account
Penalty
Summary
The facility failed to ensure a resident authorization form was in place for a resident with a personal fund account. This deficiency affected one of the six residents reviewed for personal fund accounts. The resident, who had medical diagnoses including diabetes mellitus, hyperlipidemia, anemia, and dementia, was found to have moderate cognitive impairment and required moderate staff assistance with daily activities. Despite having a personal fund account with the facility, there was no documentation to support that the resident or their representative had signed an authorization form. This was confirmed by the Business Office Manager during an interview. The facility's policy stated that written authorization was required for managing resident personal funds, but this was not adhered to in this case.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment by not completing necessary repairs in a resident's room. Specifically, Resident #60, who has diagnoses including dementia with severe psychotic disturbances, type two diabetes mellitus, anxiety, bipolar disease, and chronic pain syndrome, reported damaged drywall and a dripping bathroom faucet. The resident, who has impaired cognition with a BIMS score of 11, pointed out the issues during an interview. Observations confirmed the drywall damage and the dripping faucet, which the resident had attempted to mitigate by placing paper towels in the sink to muffle the sound. The Maintenance Director was unaware of the leaking faucet and the drywall damage, indicating a lack of communication and oversight in maintaining the resident's living conditions. The Maintenance Director stated that such repairs would typically be addressed after the resident moved out, rather than promptly fixing the issues to ensure a safe and comfortable environment. This deficiency was investigated under Complaint Number OH00151833.
Improper Application of Medical Devices Leads to Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents did not acquire pressure ulcers from medical devices in place, affecting one resident. Resident #32, who had multiple diagnoses including a fracture of the right femur, diabetes, and pressure ulcers on the bilateral buttocks, was admitted to the facility. The resident's care plan included specific instructions for immobilizing the right leg and applying Unna boots with Profore wraps, which were not followed correctly. This improper application led to the development of new pressure ulcers on the resident's right leg, including a suspected deep tissue injury and stage two pressure injuries on the right upper posterior thigh and anterior ankle. The resident's medical records and progress notes revealed that the improper placement and wrapping of the dressings and splints caused the new pressure ulcers. On multiple occasions, the resident's braces and Unna boots were not applied correctly, leading to decreased circulation and the development of fluid-filled blisters and non-blanchable areas. The Certified Nurse Practitioner (CNP) and Registered Nurse (RN) involved in the resident's care confirmed that the new wounds were due to the incorrect application of the medical devices. Interviews with the resident and staff further corroborated the findings. The resident reported issues with the braces and dressings, which led to a hospital visit for evaluation of possible blood clots. The CNP and RN both acknowledged that the new pressure ulcers were a result of the improper application of the splints and boots. Observations confirmed that the right thigh wound had healed, but the right ankle wound remained a stage two pressure ulcer. The facility's policy on pressure injury prevention and management was not adhered to, resulting in avoidable pressure ulcers for Resident #32.
Failure to Administer BiPap Machine as Ordered
Penalty
Summary
The facility failed to ensure a resident's noninvasive ventilator, specifically a BiPap machine, was administered as ordered. Resident #25, who had medical diagnoses including chronic obstructive pulmonary disease, morbid obesity, chronic kidney disease stage III, and congestive heart failure, had a physician order for BiPap mode with specific settings to be used every night shift. However, the Treatment Administration Record (TAR) for March and April 2024 showed no documentation that the BiPap was administered as ordered from 03/25/24 to 04/01/24. A nurse's progress note on 03/25/24 indicated the BiPap mask was broken, and although the respiratory company was contacted and a new mask was ordered, it was not delivered until 03/27/24. Despite the new mask's arrival, the BiPap machine was not used as ordered from 03/27/24 to 04/02/24, as confirmed by the Director of Nursing (DON). Resident #25 confirmed she had not used the BiPap machine since 03/25/24 due to the broken mask, and two masks were observed on her bedside table, with uncertainty about their functionality. The facility's policy on noninvasive ventilation stated that equipment should be replaced immediately or when available if broken or malfunctioning. The failure to administer the BiPap machine as ordered and the delay in replacing the broken mask led to non-compliance with the physician's order and the facility's policy. This deficiency was identified during a survey, which included observations, record reviews, and interviews with staff, the resident, and a representative from the respiratory company.
Failure to Monitor Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to monitor blood pressure prior to the administration of medications as ordered for Resident #24. The resident, who was admitted with diagnoses including hypertension, diabetes mellitus type II, and schizoaffective disorder, had physician orders for metoprolol tartrate and amlodipine, both with instructions to hold if the systolic blood pressure was less than 110 mm/Hg. On 04/03/24, an LPN administered these medications without obtaining the required blood pressure or heart rate values. The LPN confirmed this oversight immediately after the administration. The facility's undated medication administration policy mandates obtaining and recording vital signs when applicable or ordered by the physician. This deficiency was noted in relation to Complaint Numbers OH00151883 and OH00151405.
Failure to Prime Insulin Pen Needles
Penalty
Summary
The facility failed to ensure insulin pen needles were primed after a new needle was applied, affecting one resident observed for insulin administration. Resident #24, who has diagnoses including hypertension, diabetes mellitus type II, and schizoaffective disorder, was observed receiving an insulin injection. The LPN placed a new needle onto the insulin pen, dialed the pen to 18 units, and injected the resident without priming the needle. The LPN admitted to not priming the needle, mistakenly believing it was only necessary with a new pen. The manufacturer's product insert clearly instructs to check the flow of medication through the needle before every injection.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene during procedures for Resident #04, who had multiple medical conditions including chronic obstructive pulmonary disease, heart failure, traumatic subarachnoid hemorrhage, and hypertension. During catheter care, RN #106 did not use gloves when pulling down the resident's pants and adult incontinence briefs, and did not follow enhanced barrier precautions. Similarly, during tracheostomy care, RN #109 did not perform hand hygiene after removing gloves and did not wear a mask, despite the resident being under Enhanced Barrier Protection (EBP). Additionally, the facility failed to maintain a sanitary environment during meal service. An observation revealed that a State tested Nursing Assistant (STNA) placed a food tray on an overbed table that also had a urinal containing approximately 200 milliliters of urine. The STNA acknowledged the presence of the urinal and urine but stated that the resident preferred it to be there and would get upset if it was moved. These deficiencies were identified through staff interviews, observations, and policy reviews. The facility's policies on Enhanced Barrier Precautions and Tracheostomy Care were not adhered to, leading to lapses in infection control and hygiene practices. These issues were investigated under Complaint Numbers OH00151883 and OH00151938.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Nursing Center Of Rockford | 1 mi | ★★★★★ | 23 | 0 |
| Celina Manor | 10.6 mi | ★★★★★ | 13 | 0 |
| Gardens At Celina | 10.7 mi | ★★★★★ | 3 | 0 |
| Van Wert Manor | 11.1 mi | ★★★★★ | 0 | 0 |
| Vancrest Health Care Center | 11.1 mi | ★★★★★ | 0 | 0 |
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