Rockford, OH

Divine Rehabilitation And Nursing At Shane Hill

2-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies

10731 State Route 118, Rockford, OH

(419) 363-2620

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Divine Healthcare Management

Operator or chain grouping

Approved since

1997-04-30

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

9 facilities

Chain averages 2 overall / 2 health / 2 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.64

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.23

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.65

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.31

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.65

CMS adjusted RN staffing hours

Adjusted total hours

3.74

CMS adjusted total nurse staffing hours

Case-mix index

1.33

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

63%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,935

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

9.53

Composite VBP score used to determine payment impact.

Payment multiplier

0.9808

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

1.12

Baseline 35.85% · Performance 59.09% · Measure score 1.12 · Achievement 1.12 · Improvement 0

Adjusted total nurse staffing

0.78

Baseline 3.49 hours · Performance 3.30 hours · Measure score 0.78 · Achievement 0.78 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.54%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 53 · Observed rate 9.43% · Lower 95% interval 7.07%
Discharge to community	21.67%	50.57% 28.9 pts worse	Worse than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 12.53%
Medicare spending per beneficiary	0.79	1.02 0.2 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 2 · Denominator 2
Staff flu vaccination coverage	18.52%	42% 23.5 pts worse	Numerator 25 · Denominator 135
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.0	1.8 0.2 pts worse	1.9 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.5 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.8 0.2 pts better	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	92.4% 7.6 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.5%	94.5% 4 pts better	95.5% 3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5%
Percentage of long-stay residents experiencing one or more falls with major injury	5.4%	3.3% 2.1 pts worse	3.3% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 4.8% · Q3 4.8% · Q4 3.4% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.8%	26.1% 18.3 pts better	11.4% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.5% · Q3 7.1% · Q4 11.1% · 4Q avg 7.8%
Percentage of long-stay residents who lose too much weight	4.8%	6.2% 1.4 pts better	5.4% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.8% · Q3 9.3% · Q4 6.0% · 4Q avg 4.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.5%	25.4% 3.9 pts better	19.6% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.0% · Q3 20.0% · Q4 15.7% · 4Q avg 21.5%
Percentage of long-stay residents who received an antipsychotic medication	9.0%	11.5% 2.5 pts better	16.7% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.5% · Q3 11.6% · Q4 11.4% · 4Q avg 9.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	6.8%	7.7% 0.9 pts better	16.3% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 9.8% · Q3 6.6% · Q4 4.8% · 4Q avg 6.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.9%	6.2% 0.3 pts better	14.9% 9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 9.4% · Q3 7.4% · Q4 2.0% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.2% 0.2 pts worse	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	0.5% 0.1 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.0%	21.7% 7.7 pts better	19.8% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 14.3% · Q3 17.3% · Q4 13.5% · 4Q avg 14.0%
Percentage of long-stay residents with pressure ulcers	3.0%	3.7% 0.7 pts better	5.1% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.5% · Q3 5.1% · Q4 2.8% · 4Q avg 3.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.5%	78.1% 15.4 pts better	81.7% 11.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q3 87.0% · Q4 92.0% · 4Q avg 93.5%
Percentage of short-stay residents who had an outpatient emergency department visit	27.5%	12.5% 15 pts worse	12.0% 15.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 26.9% · Expected 10.9% · Used in QM five-star
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 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.9%	25.1% 4.8 pts worse	23.9% 6 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 23.1% · Expected 18.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-04-10 · Fire 2024-04-10

11 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-04-27 · Fire 2023-04-27

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

23 fire-safety deficiencies

Top issue: Smoke (11 deficiencies)

Cycle 3 Health 2020-02-20 · Fire 2020-02-20

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

7 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-04-10

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-17

F · Potential for more than minimal harm 2024-04-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-17

F · Potential for more than minimal harm 2024-04-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-10

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-10

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-10

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-10

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-05-17

C · Minimal harm 2024-04-10

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-05-17

C · Minimal harm 2024-04-10

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-05-17

C · Minimal harm 2024-04-10

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-05-17

F · Potential for more than minimal harm 2024-03-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-17

F · Potential for more than minimal harm 2024-03-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-17

F · Potential for more than minimal harm 2024-03-11

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-04-02

F · Potential for more than minimal harm 2023-04-27

K222 · Egress Deficiencies

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 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-06-30

E · Potential for more than minimal harm 2023-04-27

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-06-30

F · Potential for more than minimal harm 2020-02-20

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2020-03-31

F · Potential for more than minimal harm 2020-02-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-03-31

F · Potential for more than minimal harm 2020-02-20

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2020-03-31

F · Potential for more than minimal harm 2020-02-20

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2020-03-31

F · Potential for more than minimal harm 2020-02-20

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2020-03-31

E · Potential for more than minimal harm 2020-02-20

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2020-03-31

C · Minimal harm 2020-02-20

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2020-03-31

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-04

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-05-12

D · Potential for more than minimal harm 2025-06-04

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-05-12

D · Potential for more than minimal harm 2025-03-14

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-03-31

D · Potential for more than minimal harm 2024-11-21

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-11-05

E · Potential for more than minimal harm 2024-04-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-10

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-10

F584 · Resident Rights Deficiencies

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 2024-05-17

D · Potential for more than minimal harm 2024-04-10

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-10

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-17

F · Potential for more than minimal harm 2023-04-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-04-27

F947 · Nursing and Physician Services Deficiencies

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 2023-06-30

D · Potential for more than minimal harm 2023-04-27

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-04-27

F657 · Resident Assessment and Care Planning Deficiencies

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 2023-06-30

D · Potential for more than minimal harm 2023-04-27

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-06-30

E · Potential for more than minimal harm 2020-02-20

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2020-03-31

E · Potential for more than minimal harm 2020-02-20

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2020-03-31

E · Potential for more than minimal harm 2020-02-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2020-03-31

D · Potential for more than minimal harm 2020-02-20

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2020-03-31

D · Potential for more than minimal harm 2020-02-20

F761 · Pharmacy Service Deficiencies

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 2020-03-31

D · Potential for more than minimal harm 2020-02-20