Health inspection·April 14, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, and policy review, the facility failed to ensure a resident was provided with showers. This affected one (#21) out of four residents reviewed for showering. The facility census was 42. Residents Affected - Few Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis included spinal stenosis. Review of the care plan dated 09/22/23 revealed Resident #21 was at risk for decline in activities of daily living (ADL) function related to weakness alteration in ADL performance/participation, chronic obstructive pulmonary disease, obesity, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident requires partial assistance for toileting hygiene, bathing, lower body dressing, and personal hygiene. Review of the MDS also revealed Resident #21 was cognitively intact. Review of physician order dated 03/15/24 revealed an order for Vitamin A & Vitamin D (A&D) Ointment to moisture associated skin damage (MASD) - bilateral buttocks. Apply after each incontinent episode, as needed for Moisture Associated Skin Damage. Apply after each incontinent episode. Interview on 04/13/24 at 7:32 A.M. with State Tested Nursing Assistant (STNA) #292 confirmed on 04/01/24 Resident #21 did not get a shower. Interview with STNA #292 confirmed she marked No in the computerized charting instead of refusal because he did not refuse his shower. Interview on 04/13/24 at 8:48 A.M. with Resident #21 confirmed he does not always get his shower and that he did not receive a shower on 04/01/24 and he did not receive his shower a couple of times in the last two weeks. Resident #21 reports he does not like to miss his showers due to being a heavier person who can not perform all his own cares. Interview on 04/14/24 at 9:54 A.M. with STNA #292 confirmed a shower sheet dated 04/01/24 showing Resident #21 refused his shower. Interview with STNA #292 confirmed the Director of Nursing (DON) came to her this morning, 04/14/24, with a shower sheet and asked her to fill it out for Resident #21 with a date of 04/01/24 and to write Refused across the top. Interview on 04/14/24 at 10:30 A.M. with the DON confirmed she did have STNA #92 complete a shower sheet this morning for Resident #21. The DON confirmed she did not make STNA #292 fill it out, she Page 1 of 4 365297 365297 04/14/2024 Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked her to fill it out with a date of 04/01/24 and the comment Refused across the top of the shower sheet. Interview with the DON also confirmed she knows Resident #21 did not refuse a shower on 04/01/24, but sometimes he does and she just wanted to give the surveyor something. The DON confirmed the documentation reflecting Resident #21 refused the shower would not be accurate and the documentation will be corrected to accurately reflect the resident did not receive a shower. Interview with the DON also confirmed Resident #21's Brief Interview of Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Further review of the Shower Schedule dated 04/04/24 revealed residents are schedule for a shower two times weekly. Shower sheets are to be signed by the nurse on duty NO EXCEPTIONS. A refusal of care MUST be reported to the nurse on duty and documented in computer charting system. Review of the Follow Up Question Report for Resident #21 revealed on 03/28/24 and 04/01/24 for bathing the task completed response was no. Review of the Bath, Shower/Tub policy dated 02/18 revealed the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Reporting: Notify the supervisor if the resident refuses the shower/tub bath. Report other information in accordance with facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00152522. 365297 Page 2 of 4 365297 04/14/2024 Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews and policy review, the facility failed to ensure documentation was accurate regarding a resident's showers. This affected one (#21) out of four residents reviewed for accuracy of the medical records. Facility census was 42. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis included spinal stenosis. Review of the care plan dated 09/22/23 revealed Resident #21 was at risk for decline in activities of daily living (ADL) function related to weakness alteration in ADL performance/participation, chronic obstructive pulmonary disease, obesity, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident requires partial assistance for toileting hygiene, bathing, lower body dressing, and personal hygiene. Review of the MDS also revealed Resident #21 was cognitively intact. Review of physician order dated 03/15/24 revealed an order for Vitamin A & Vitamin D (A&D) Ointment to moisture associated skin damage (MASD) - bilateral buttocks. Apply after each incontinent episode, as needed for Moisture Associated Skin Damage. Apply after each incontinent episode. Interview on 04/13/24 at 7:32 A.M. with State Tested Nursing Assistant (STNA) #292 confirmed on 04/01/24 Resident #21 did not get a shower. Interview with STNA #292 confirmed she marked No in the computerized charting instead of refusal because he did not refuse his shower. Interview on 04/13/24 at 8:48 A.M. with Resident #21 confirmed he does not always get his shower and that he did not receive a shower on 04/01/24 and he did not receive his shower a couple of times in the last two weeks. Resident #21 reports he does not like to miss his showers due to being a heavier person who can not perform all his own cares. Interview on 04/14/24 at 9:54 A.M. with STNA #292 confirmed a shower sheet dated 04/01/24 showing Resident #21 refused his shower. Interview with STNA #292 confirmed the Director of Nursing (DON) came to her this morning, 04/14/24, with a shower sheet and asked her to fill it out for Resident #21 with a date of 04/01/24 and to write Refused across the top. Interview on 04/14/24 at 10:30 A.M. with the DON confirmed she did have STNA #92 complete a shower sheet this morning for Resident #21. The DON confirmed she did not make STNA #292 fill it out, she asked her to fill it out with a date of 04/01/24 and the comment Refused across the top of the shower sheet. Interview with the DON also confirmed she knows Resident #21 did not refuse a shower on 04/01/24, but sometimes he does and she just wanted to give the surveyor something. The DON confirmed the documentation reflecting Resident #21 refused the shower would not be accurate and the documentation will be corrected to accurately reflect the resident did not receive a shower. Interview with the DON also confirmed Resident #21's Brief Interview of Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. 365297 Page 3 of 4 365297 04/14/2024 Shelby Skilled Nursing and Rehabilitation 705 Fulton Street Sidney, OH 45365

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the Shower Schedule dated 04/04/24 revealed residents are schedule for a shower two times weekly. Shower sheets are to be signed by the nurse on duty NO EXCEPTIONS. A refusal of care MUST be reported to the nurse on duty and documented in computer charting system. Review of the Follow Up Question Report for Resident #21 revealed on 03/28/24 and 04/01/24 for bathing the task completed response was no. Review of the Bath, Shower/Tub policy dated 02/18 revealed the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Reporting: Notify the supervisor if the resident refuses the shower/tub bath. Report other information in accordance with facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00152522. 365297 Page 4 of 4