Divine Rehabilitation and Nursing at Shane Hill

In the surveyor’s words

From the most serious findings on record at Divine Rehabilitation and Nursing at Shane Hill, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Apr 27, 2023

  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. Findings include: 1. Review of Resident #165's medical record revealed an admitted d of 12/22/22. […]

• No harm, potential for more than minimal, widespreadF947Apr 27, 2023

  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. […]

• No harm, potential for more than minimal, patternF812Jun 11, 2026

  Based on observation, staff interview, and policy review, the facility failed to ensure safe temperatures were maintained and documented for resident personal refrigerators. This deficient practice affected four (#7, #37, #38, and #40) of four residents reviewed for personal refrigerators. The facility census was 54.Findings include:Observation on 06/08/26 at 9:50 A.M. revealed Resident #37 had a personal refrigerator with soda and bologna inside. The refrigerator had no thermometer or documented monitoring of temperatures.Observation on 06/08/26 at 10:00 A.M. revealed Resident #7 had a personal refrigerator with nutritional shakes, soda, cheese, energy drink, and candy inside. […]

• No harm, potential for more than minimal, patternF689Apr 10, 2024

  Based on record review and staff interviews, the facility failed to ensure residents were free of potential hazards and accidents. This affected one (#60) resident and had the ability to affect 19 additional residents (#7, #8, #11, #14, #28, #29, #30, #34, #36, #39, #40, #41, #48, #50, #51, #53, #56, #58, and #59) in the memory unit who were cognitively impaired and independently mobile. The facility census was 64. Findings include: Review of medical record for Resident #60 revealed admitted [DATE]. The resident was admitted with diagnoses including dementia with severe psychotic disturbances, type two diabetes mellitus, anxiety, Bipolar Disease, and chronic pain syndrome. […]

• No harm, potential for more than minimal, isolatedF550Jun 11, 2026

  Based on observation, medical record review, resident and resident representative interview, staff interview, and review of posted meal times, the facility failed to serve meals in a manner to preserve resident dignity. This affected two (#45 and #10) of two residents directly observed during meals. The facility census was 54.Findings include:1. Observation on 06/08/26 at 12:30 P.M. revealed 14 residents seated in the dining room at seven tables. Two residents were assisted to eat by two staff members at one table. Two tables had one resident seated at a table with two additional residents which had food and were eating while the other two residents waited. […]