Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DIVINE REHABILITATION AND NURSING AT SHANE HILL
ROCKFORD, OH · 69 certified beds · Last Life Safety survey April 10, 2024
CMS Certification Number 366125 · first certified April 1997
Ownership
Operated by DIVINE HEALTHCARE MANAGEMENT · For profit - Corporation
- Ownership changed December 1, 2020 (change of ownership)from THE LAURELS OF ROCKFORD, INC.
Position within OH
30 citations — more than 87% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 10 citations; the earlier surveys in the window averaged 7.5. With 5 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: December 2025 to December 2026. This facility’s last Life Safety survey was April 2024. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 30 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 30 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 30 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 20, 2020 | 7 |
| April 27, 2023 | 10 |
| March 11, 2024 | 3 |
| April 10, 2024 | 10 |
| April 10, 2024 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 4 | 2024-04-10 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2024-04-10 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2 | 2024-04-10 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 2 | 2024-04-10 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2024-04-10 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2023-04-27 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-04-10 |
| K-0711 | Provide a written emergency evacuation plan. | 2 | 2023-04-27 |
What the citations cover
- Smoke Deficiencies 13
- Emergency Preparedness Deficiencies 4
- Miscellaneous Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Emergency Preparedness Deficiencies | 4 |
| Miscellaneous Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 10, 2024 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has plan of correction (May 17, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has plan of correction (May 17, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has plan of correction (May 17, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 17, 2024) |
March 11, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 17, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (April 2, 2024) |
April 27, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 30, 2023) |
February 20, 2020 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has plan of correction (March 31, 2020) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 31, 2020) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 31, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 31, 2020) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 31, 2020) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (March 31, 2020) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 31, 2020) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.