Health inspection·June 13, 2019

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, review of self reported incidents (SRI's) and policy review, the facility failed to ensure residents were free from physical abuse. This affected three (#6, #20 and #14) out of four residents reviewed for abuse. The facility census was 33. Findings include: 1. Review of medical record for Resident #20 revealed an admission dated of 10/08/07 with diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder, cognitive communication deficit, pseudobulbar effect, unsteady on feet, altered mental status, unspecified psychosis and dysphagia. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #20 was assessed as cognitively intact with no deficits. She also was assessed as having physical and verbal behavioral symptoms directed towards others. Review of comprehensive care plan documented Resident #20 is at risk for adverse reactions from behavioral disturbances related to being verbally abusive, is socially inappropriate, she can get upset if she does not get her way and her behavior is hard to redirect. Further review documented a goal the resident will verbalize acknowledgements of the needed to control behavioral symptoms. She then had an interventions for staff to intervene during behavioral outburst to protect the safety of the residents and others. Review of nursing note dated 04/11/19 documented Resident #20 had an altercation with another resident. Resident #20 was documented as verbally yelling and cursing at and hit the other resident in the chin with her hand. The other resident attempted to grab Resident #20 and grabbed her arm to stop her and Resident #20 obtained a small skin tear to her left forearm. The incident was reported to the Administrator. Review of medical record for Resident #6 reveled an admission date of 06/06/18 with diagnoses including peripheral vascular disease, heart failure, weakness, major depression, hypertension, muscle weakness and diabetes type two. Review of Quarterly MDS assessment dated [DATE] documented Resident #6 was assessed as cognitively intact with no deficits. He had no behaviors assessed at this time Review of comprehensive care plan documented Resident #6 has a problematic manner in which residents acts characterized by verbally inappropriate behavior. Further review documented a goal to reduce episodes of manipulative behavior. She also had a care planned intervention to redirect the resident from a public area when her behavior is disruptive. Review of nurses note dated 04/11/19 documented Resident #6 was in an altercation with another resident. The other resident was yelling at Resident #6 in the dining area while the resident was having a discussion with another staff member. Resident #6 yelled back and the other resident hit her in the chin with her hand. The residents were redirected and separated. The Administrator was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 2 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a SRI documented on 04/11/19 Resident #20 entered the dining room. Resident #6 entered the dining room and interrupted Resident #20 conversation with dietary staff. Resident #20 then told Resident #6 to shut up. Then Resident #6 told Resident #20 to shut up. Resident #20 then swung at Resident #6 and hit her in the right side of her chin resulting in Resident #6 grabbing her arm. The resident were separated immediately and assessed. Further review documented the facility unsubstantiated the allegation of physical abuse because both resident were not trying to intentionally hurt each other. Education was given to both residents about bringing disagreements to the staff. On 06/10/19 at 10:39 A.M. interview with Resident #6 revealed she was waiting to smoke and the employee that was suppose to help us wasn't there. Resident #6 stated she went to the dining room to find the employee and asked the person in the kitchen where the staff member was. She said she didn't know and shut the door so she knocked again. Resident #20 was sitting by the kitchen door and said why don't you shut your mouth you stupid derogatory name. Resident #6 stated she called her the stupid derogatory name back. Resident #6 stated then Resident #20 went to hit her and she just barely landed the hit on my chin. Resident #6 stated she reacted to the hit by grabbing her arm. We both went our separate ways and staff came down to talk to me about the incident. The hit to the chin didn't hurt but grabbing her was a reaction. On 06/10/19 11:16 A.M. interview with the Resident #20 revealed the resident was in the dining room trying to talk to the cook about what she wanted for her meal and Resident #6 came in and rudely interrupted me. She revealed she thought Resident #6 was going to hit her so she started swinging her arms to protect herself. She further revealed while swinging her arms Resident #6 must have been reaching for me and scratched me. 2. Review of the medical record for Resident #32 revealed an admission date of 01/26/19 with diagnoses including anxiety, insomnia, and cognitive communication deficit. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #32 was identified as moderately cognitively impaired with behaviors including physical and verbal behaviors directed towards others and self. Review of the comprehensive care plan for Resident #32 revealed the resident has problematic behaviors characterized by ineffective coping and verbal/physical aggression episodes. Further review revealed Resident #32 had a goal of not striking others and to ensure the safety for residents. Review of the care plan interventions included routine checks as indicated for safety and redirection and assist resident to quiet area/room when becoming agitated. Review of the social services note dated 04/22/19 at 07:11 A.M. revealed Resident #32 had an incident with Resident #14 on 04/20/19. Further review revealed Resident #32 pushed Resident #14 on the bed, drew back their fist, and was ready to hit Resident #14. Resident #14 was safely accompanied to the dining room by staff. Resident #14 told staff that she was afraid Resident #32 would try to hit her and wanted to call her son, Resident #14 then called her son. The Administrator was notified of the incident and stated that she was coming in and would take care of it. It was documented that Resident #32 was moved to a different room. Review of the medical record for Resident #14 revealed an admission date of 11/30/18 with diagnoses including dementia, depression, anxiety, and panic disorder. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #14 was identified as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 3 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0600 cognitively intact with no aggressive behaviors. Level of Harm - Minimal harm or potential for actual harm Review of the comprehensive care plan for Resident #14 revealed the resident is at risk for mood problems and fluctuations related to depression, anxiety, and dementia. Further review revealed Resident #14 had a goal for the resident to express concerns. Review of the care plan interventions included assessment of the reason/cause of mood problems, correct mood problems if possible, and offer emotional support as desired/accepted by the resident. Residents Affected - Few Review of the nursing note dated 04/20/19 at 10:05 A.M. revealed Resident #14's son and physician were notified of the incident that occurred on 04/20/19. Further review revealed Resident #14 stated I am not hurt. Review of the SRI dated 04/20/19 revealed on 04/20/19 Resident #32 and Resident #14 were in their room having a conversation when Resident #32 became agitated with Resident #14 and pushed Resident #14. Further review of the SRI revealed the residents were immediately separated and there was no injuries. Resident #32 told the Administrator that he/she was not trying to harm Resident #14. The facility unsubstantiated the allegation of physical abuse due to Resident #32 reporting that he/she was not trying to intentionally harm Resident #14. Interview with Resident #32 on 06/10/19 at 8:40 A.M. revealed Resident #32 was not able to appropriately answer questions regarding the incident that occured on 04/20/19. Interview with Resident #14 on 06/10/19 at 2:51 P.M. revealed Resident #14 did not feel like he/she was abused and was not fearful of Resident #32. On 06/12/19 at 2:33 P.M. interview with Administrator verified Resident #20 did hit Resident #6 in her chin with her hand after a verbal altercation. She then verified Resident #6 grab her arm to protect herself. She then verified Resident #14 was pushed by Resident #32 and Resident #32 raised her fist but never hit Resident #14. She also verified Resident #14 is alert and oriented and was scared by the incident. She was in agreement the acts were willful as defined in the State Operations Manual (SOM) but neither of the residents meant to cause harm or injury to each other. On 06/12/19 at 2:32 P.M. interview with [NAME] President of Operations verified the acts of physical abuse were willful as defined in the SOM. She further verified the SRI's were unsubstantiated due to measures put into place to ensure all the resident who were involved were safe and there was no further incidents. She also verified all residents have the right to be free from abuse as required per the regulations. Review facilities policy for Abuse prohibition dated April 2019 documented the facility will not tolerate neglect, abuse, and misappropriation of resident funds or property by anyone. The policy also contained a definition of abuse which included willful meaning meaning infliction of injury, unreasonable confinement, intimidation, or punishment resulting in harm,pain or mental anguish. Further review of the facilities policy identified physical abuse as hitting, slapping, pinching and kicking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 4 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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, resident and staff interview, review of self reported incidents (SRI's) and policy review, the facility failed implement their abuse policy to ensure residents were free from physical abuse. This affected three (#6, #20 and #14) out of four residents reviewed for abuse. The facility census was 33. Residents Affected - Few Findings include: 1. Review of medical record for Resident #20 revealed an admission dated of 10/08/07 with diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder, cognitive communication deficit, pseudobulbar effect, unsteady on feet, altered mental status, unspecified psychosis and dysphagia. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #20 was assessed as cognitively intact with no deficits. She also was assessed as having physical and verbal behavioral symptoms directed towards others. Review of comprehensive care plan documented Resident #20 is at risk for adverse reactions from behavioral disturbances related to being verbally abusive, is socially inappropriate, she can get upset if she does not get her way and her behavior is hard to redirect. Further review documented a goal the resident will verbalize acknowledgements of the needed to control behavioral symptoms. She then had an interventions for staff to intervene during behavioral outburst to protect the safety of the residents and others. Review of nursing note dated 04/11/19 documented Resident #20 had an altercation with another resident. Resident #20 was documented as verbally yelling and cursing at and hit the other resident in the chin with her hand. The other resident attempted to grab Resident #20 and grabbed her arm to stop her and Resident #20 obtained a small skin tear to her left forearm. The incident was reported to the Administrator. Review of medical record for Resident #6 reveled an admission date of 06/06/18 with diagnoses including peripheral vascular disease, heart failure, weakness, major depression, hypertension, muscle weakness and diabetes type two. Review of Quarterly MDS assessment dated [DATE] documented Resident #6 was assessed as cognitively intact with no deficits. He had no behaviors assessed at this time Review of comprehensive care plan documented Resident #6 has a problematic manner in which residents acts characterized by verbally inappropriate behavior. Further review documented a goal to reduce episodes of manipulative behavior. She also had a care planned intervention to redirect the resident from a public area when her behavior is disruptive. Review of nurses note dated 04/11/19 documented Resident #6 was in an altercation with another resident. The other resident was yelling at Resident #6 in the dining area while the resident was having a discussion with another staff member. Resident #6 yelled back and the other resident hit her in the chin with her hand. The residents were redirected and separated. The Administrator was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 5 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a SRI documented on 04/11/19 Resident #20 entered the dining room. Resident #6 entered the dining room and interrupted Resident #20 conversation with dietary staff. Resident #20 then told Resident #6 to shut up. Then Resident #6 told Resident #20 to shut up. Resident #20 then swung at Resident #6 and hit her in the right side of her chin resulting in Resident #6 grabbing her arm. The resident were separated immediately and assessed. Further review documented the facility unsubstantiated the allegation of physical abuse because both resident were not trying to intentionally hurt each other. Education was given to both residents about bringing disagreements to the staff. On 06/10/19 at 10:39 A.M. interview with Resident #6 revealed she was waiting to smoke and the employee that was suppose to help us wasn't there. Resident #6 stated she went to the dining room to find the employee and asked the person in the kitchen where the staff member was. She said she didn't know and shut the door so she knocked again. Resident #20 was sitting by the kitchen door and said why don't you shut your mouth you stupid derogatory name. Resident #6 stated she called her the stupid derogatory name back. Resident #6 stated then Resident #20 went to hit her and she just barely landed the hit on my chin. Resident #6 stated she reacted to the hit by grabbing her arm. We both went our separate ways and staff came down to talk to me about the incident. The hit to the chin didn't hurt but grabbing her was a reaction. On 06/10/19 11:16 A.M. interview with the Resident #20 revealed the resident was in the dining room trying to talk to the cook about what she wanted for her meal and Resident #6 came in and rudely interrupted me. She revealed she thought Resident #6 was going to hit her so she started swinging her arms to protect herself. She further revealed while swinging her arms Resident #6 must have been reaching for me and scratched me. 2. Review of the medical record for Resident #32 revealed an admission date of 01/26/19 with diagnoses including anxiety, insomnia, and cognitive communication deficit. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #32 was identified as moderately cognitively impaired with behaviors including physical and verbal behaviors directed towards others and self. Review of the comprehensive care plan for Resident #32 revealed the resident has problematic behaviors characterized by ineffective coping and verbal/physical aggression episodes. Further review revealed Resident #32 had a goal of not striking others and to ensure the safety for residents. Review of the care plan interventions included routine checks as indicated for safety and redirection and assist resident to quiet area/room when becoming agitated. Review of the social services note dated 04/22/19 at 07:11 A.M. revealed Resident #32 had an incident with Resident #14 on 04/20/19. Further review revealed Resident #32 pushed Resident #14 on the bed, drew back their fist, and was ready to hit Resident #14. Resident #14 was safely accompanied to the dining room by staff. Resident #14 told staff that she was afraid Resident #32 would try to hit her and wanted to call her son, Resident #14 then called her son. The Administrator was notified of the incident and stated that she was coming in and would take care of it. It was documented that Resident #32 was moved to a different room. Review of the medical record for Resident #14 revealed an admission date of 11/30/18 with diagnoses including dementia, depression, anxiety, and panic disorder. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #14 was identified as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 6 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0607 cognitively intact with no aggressive behaviors. Level of Harm - Minimal harm or potential for actual harm Review of the comprehensive care plan for Resident #14 revealed the resident is at risk for mood problems and fluctuations related to depression, anxiety, and dementia. Further review revealed Resident #14 had a goal for the resident to express concerns. Review of the care plan interventions included assessment of the reason/cause of mood problems, correct mood problems if possible, and offer emotional support as desired/accepted by the resident. Residents Affected - Few Review of the nursing note dated 04/20/19 at 10:05 A.M. revealed Resident #14's son and physician were notified of the incident that occurred on 04/20/19. Further review revealed Resident #14 stated I am not hurt. Review of the SRI dated 04/20/19 revealed on 04/20/19 Resident #32 and Resident #14 were in their room having a conversation when Resident #32 became agitated with Resident #14 and pushed Resident #14. Further review of the SRI revealed the residents were immediately separated and there was no injuries. Resident #32 told the Administrator that he/she was not trying to harm Resident #14. The facility unsubstantiated the allegation of physical abuse due to Resident #32 reporting that he/she was not trying to intentionally harm Resident #14. Interview with Resident #32 on 06/10/19 at 8:40 A.M. revealed Resident #32 was not able to appropriately answer questions regarding the incident that occured on 04/20/19. Interview with Resident #14 on 06/10/19 at 2:51 P.M. revealed Resident #14 did not feel like he/she was abused and was not fearful of Resident #32. On 06/12/19 at 2:33 P.M. interview with Administrator verified Resident #20 did hit Resident #6 in her chin with her hand after a verbal altercation. She then verified Resident #6 grab her arm to protect herself. She then verified Resident #14 was pushed by Resident #32 and Resident #32 raised her fist but never hit Resident #14. She also verified Resident #14 is alert and oriented and was scared by the incident. She was in agreement the acts were willful as defined in the State Operations Manual (SOM) but neither of the residents meant to cause harm or injury to each other. On 06/12/19 at 2:32 P.M. interview with [NAME] President of Operations verified the acts of physical abuse were willful as defined in the SOM. She further verified the SRI's were unsubstantiated due to measures put into place to ensure all the resident who were involved were safe and there was no further incidents. She also verified all residents have the right to be free from abuse as required per the regulations. Review facilities policy for Abuse prohibition dated April 2019 documented the facility will not tolerate neglect, abuse, and misappropriation of resident funds or property by anyone. The policy also contained a definition of abuse which included willful meaning meaning infliction of injury, unreasonable confinement, intimidation, or punishment resulting in harm,pain or mental anguish. Further review of the facilities policy identified physical abuse as hitting, slapping, pinching and kicking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 7 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure transfer/discharge notices included understandable written notification as to the medical condition requiring transfer to the hospital for medical evaluation. This affected one (#26) of two residents reviewed for hospitalizations. The census was 33. Findings include: Review of the medical record for Resident #26 revealed an admission date of 12/01/18 with diagnoses including Diabetes Mellitus type two, depression, heart failure, and chronic obstructive pulmonary disease. Further review of the medical record revealed Resident #26 was transferred to the hospital on [DATE] due to being unresponsive and 06/10/19 due to pneumonia. Review of the facility transfer notification form for Resident #26 dated 06/08/19 revealed Resident #26 was transferred to the hospital on [DATE] for additional medical evaluation and follow up. Further review of the facility transfer form for Resident #26 dated 06/08/19 revealed the transfer notification did not include any information regarding the specific medical condition requiring Resident #26 to be transferred to the hospital. Review of the facility transfer notification form for Resident #26 dated 06/10/19 revealed Resident #26 was transferred to the hospital on [DATE] for additional medical evaluation and follow up. Further review of the facility transfer form for Resident #26 dated 06/10/19 revealed the transfer notification did not include any information regarding the specific medical condition requiring Resident #26 to be transferred to the hospital. Interview on with [NAME] President of Operations #109 on 06/12/19 at 11:24 A.M. verified Resident #26's facility transfer notifications dated 06/08/19 and 06/10/19 did not include the specific medical condition requiring Resident #26 to be transferred to the hospital. Review of the policy titled Transfer or Discharge Notice last revised December 2016 revealed the resident and/or representative will be notified in writing of the reason for the transfer or discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 8 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure insomnia was part of the comprehensive care plan which was being treated with a psychotropic medication. This affected one (#19) out of five resident reviewed for unnecessary medication. The facility census was 33. Findings include: Review of medical record for Resident #19 reveal an admission date of 11/30/17 with diagnoses that include chronic obstructive pulmonary disease (lung disease), osteoarthritis, congestive heart failure, anxiety, rheumatoid arthritis, chronic pain syndrome, opioid dependence, high blood pressure, insomnia, weakness, overactive bladder, artificial knee, hypothyroidism, nicotine dependence, acid reflux disease, bipolar disorder (mental disorder) and anemia. Review of the Comprehensive Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed intact cognition. Resident requires supervision with bed mobility, transfers and eating. Extensive assist with one staff member is required for dressing, toileting and personal hygiene. Insomnia is coded as current medical condition for Resident #19 and she was receiving antidepressants during the assessment period for insomnia. Review of comprehensive plan of care initialed on 12/17/18 was silent regarding treatment plan for insomnia. Review of Medication Administration record for the month of June 2019 for Resident #19 revealed was receiving Trazadone (antidepressant) 50 milligrams mg daily for insomnia. Review of Physician orders for the month of June 2019 for Resident #19 revealed was receiving Trazadone (antidepressant) 50 milligrams mg daily for insomnia. Interview with Acting Director of Nursing #105 on 06/13/19 at 1:39 P.M., verified that Resident #19's comprehensive plan of care did not include insomnia and it should have. No policy available for review provided during the survey period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 9 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of information from Medscape, the facility failed to ensure appropriate behavior monitoring for hallucinations was in place for the use an antipsychotic medication. This affected one (#5) out of five residents reviewed for psychotropic medication. The facility census was 33. Residents Affected - Few Findings include: Medical record review for Resident #5 reveals an admission date of 06/10/2010 with diagnoses that include but not limited to dementia with Lewy bodies (progressive disease that affects cognition), dementia with behavioral disturbances, pressure ulcers, Parkinson's disease, psychotic disorder with delusions, epilepsy, adult failure to thrive, malnutrition, psychosis, restless and agitation, chronic atrial fibrillation, type two diabetes, anxiety disorder, mild intellectual disabilities, heart failure. Review of plan of care dated 12/17/18 for Resident #5 revealed resident uses antipsychotic medications related to Lewy Body Dementia with behavioral disturbance, psychosis, and hallucinations. Interventions include administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift, complete Abnormal Involuntary Movement Scale (AIMS) test every six months and as needed, consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly, discuss with physician, family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication being given, monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, extrapyramidal symptoms (EPS) including shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person, and monitor/record occurrence of for target behavior symptoms (hallucinations) and document per facility protocol. Review of most recent quarterly Minimum data set (MDS) for Resident #5 dated 03/29/19 revealed impaired cognition. Resident #5 required extensive assist for bed mobility, transfers, dressing eating and toileting. Resident #5 was totally dependent for personal hygiene. Further investigation revealed resident was receiving antipsychotic medication during the assessment period and there was no any hallucinations observed for the same assessment period. Review of most recent significant change MDS for Resident #5 dated 12/31/19 revealed an impaired cognition. Resident #5 required extensive assist for bed mobility, transfers, dressing eating and toileting. Resident #5 was totally dependent for personal hygiene. Further investigation revealed resident was receiving antipsychotic medication during the assessment period and there was not any hallucinations observed for the same assessment period. Review of Physician orders for Resident #5 for the month of June 2019 revealed an order dated 12/01/18 for Nuplazid (psychotropic name brand medication) 34 milligrams one tablet daily. Review of Nursing Notes for Resident #5 from 11/01/19 thru 06/14/19 was silent for hallucinations monitoring or hallucination events. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 10 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of risk verses benefit for use of antipsychotic medication (consent form to use medication from family) for Resident #5 dated 12/17/18 revealed resident was experiencing hallucinations of people hurting others and visual disturbances of people who were not there as an indication of use for antipsychotic medication. The document was signed by physician, family member and Director of Nursing. Review of risk verses benefit for use of antipsychotic medication for Resident #5 dated 03/22/19 revealed no indications that the resident was experiencing hallucinations of people hurting others and visual disturbances. The document was signed by the Physician, Director of Nursing and a verbal consent to the use of antipsychotic medication from a family member. Review of facility target drug monitoring tool for Resident #5 for the months of January, February, March, April, May and June 2019 revealed yelling out, crying and anxiety were the targeted behaviors not hallucinations. Interview with [NAME] President of Operations #109 on 06/13/19 at 10:31 A.M. verified that the monitoring for targeting behaviors were not the correct targeting behaviors. [NAME] President of Operations #109 confirmed there was no behavior monitoring regarding hallucinations available in Resident #5's medical record. No policy for monitoring the targeted behaviors was available for review during the survey. Review of medication information obtained from Medscape revealed Nuplazid is an antipsychotic medication. Nuplazid is used for Parkinson Disease Psychosis and is indicated in the treatment of hallucinations and delusions associated with Parkinson disease psychosis FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 11 of 12 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 365297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation and staff interview, the facility failed to ensure expired medications and supplies were discarded appropriately. This had the potential to affect all 33 residents in the facility. The census was 33. Findings include: Observation of the medication room on the East Unit on 06/11/19 at 9:35 A.M. revealed the following: two disposable respiratory gas bubble humidifiers with an expiration date of 05/11/17 and two disposable respiratory gas bubble humidifiers with an expiration date of 10/02/18, one new unopened bottle of vitamin C with an expiration date of 10/18, five bottles of unopened Optimum iron free formula multiple vitamins with an expiration date of 07/18, Optimum Vitamin B12 one unopened bottle of 100 tablets with an expiration date of 02/2018, one box (five milliliters) of unopened evencare G3 glucose control solutions (used to test blood sugar testing equipment) with an expiration date of 04/2019, two unopened tubes of convatec stomaahesive skin barrier with an expiration date of 09/2016, six bottles of unopened Omeprazole acid reducer bottles with an expiration date 12/2018 and one bottle of acid gone 100 chewable tabs with an expiration date of 08/2018 all being stored during the survey in the medication room. One unopened bottle of Floucinolone Acetonide labeled from the pharmacy for Resident #20 had an expiration date of 02/2019. Interview with the Licensed Practical Nurse #103 on 06/11/19 at 10:10 A.M. verified the above findings and states that all expired medications should be discarded or returned to the pharmacy. The facility confirmed this had the potential to affect all 33 residents residing in the facility. No policy was available for review during the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365297 If continuation sheet Page 12 of 12