Health inspection·June 16, 2022

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on resident record review, staff interview, and review of a facility policy; the facility failed to respond to pharmacy medication regimen reviews in a timely manner. This affected one (#16) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: Medical record review for Resident #16 revealed admission date 10/08/07. Diagnoses included dementia with behavioral disturbance and presence of right artificial knee joint. Review of physician orders dated 04/29/21 revealed Doxycycline 100 milligrams (mg) two times a day for infection, end date 08/30/21. Review of physician orders dated 11/23/21 revealed Memantine 5 mg give two tablets by mouth one time a day and give one tablet by mouth at bedtime. Review of the Consultation Report dated 06/10/21 revealed repeated recommendation from 04/29/21. Resident receives Doxycycline 100 milligrams (mg) orally twice a day since 04/20/21. The order does not list a stop date. Physician's Response: I have re-evaluated this therapy and wish to implement the following changes: Stop Doxy, undated. Review of the Consultation Report dated 08/03/21 revealed Resident receives Memantine Hydrochloride 5 mg two times a day and has tolerated treatment for at least one continuous week. No orders were found in the medical record to up-titrate the dose. Please up-titrate the dose as follows: 10 mg each morning (AM) and 5 mg each nighttime (PM) for seven days, then 10 mg twice daily as a maintenance dose. Rationale for recommendation: The usual dose of memantine is 20 mg/day for the immediate-release formulation, or 28 mg/day for the extended-release (XR) formulation. A handwritten notation to See Response was noted. There was no Physician's Response checked, no physician signature or date. Consultation Report dated 10/05/21 revealed the above recommendation. Physician's Response: I accept the recommendations above, please implement as written. Increase Memantine to 10 mg every AM and 5 mg PM, dated 10/05/21. These findings were verified on 06/15/22 at 2:53 P.M. by Regional Quality Assurance Nurse #553. The Regional Nurse stated the notation See Response for 08/03/21 reflected the Physician's Response dated 10/05/21. The Regional Quality Assurance Nurse stated she had been on maternity leave and when she came back, she had to follow-up on tasks that were incomplete. She stated the Director of Nursing and Assistant Director of Nursing were new to their roles and she had to train them. Review of facility policy titled Medication Regimen Reviews, dated 05/2019, revealed the Consultant Pharmacist reviews the medication regimen of each resident at least monthly. 1. The Consultant (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365297 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 06/16/2022 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)