Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Residents Affected - Few
Based on medical record reviews, staff and resident interviews, facility investigation reviews, and facility
policy review, the facility failed to ensure resident's medications were administered as ordered resulting in
significant medication errors. This affected two (#12 and #13) out of four reviewed for medication
administration. The facility census was 36.
Findings include:
1. Review of the medical record for Resident #13 revealed an admission date of 06/06/23 with medical
diagnoses of osteoarthritis, gout, hyperparathyroidism, diabetes mellitus (DM), obesity, end stage renal
disease (ESRD), and atrial fibrillation.
Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment,
dated 03/19/24, which indicated Resident #13 was cognitively intact and required moderate staff assistance
with toilet hygiene and bed mobility and maximum staff assistance with bathing and transfers.
Review of a facility investigation report, dated 04/10/24, stated Resident #13 was inadvertently
administered a dose of Lyrica in error. The report did not indicate the dose of Lyrica that was administered.
The report stated Resident #13 complained of feeling loopy but denied any pain or dizziness. The report
continued to indicate Resident #13 stated she received a white pill in the morning. The report stated
Resident #13's nurse prepared another resident's medications and was interrupted during the task to assist
another staff member. The report stated the nurse locked the prepared medications in the medication cart
and when she returned, she mistakenly administered the wrong medication to Resident #13. Per the report,
Resident #13 remained alert and oriented to person, place, time, and situation and did not have adverse
reaction to the medication administration error. Per the investigation report, the facility staff monitored
Resident #13 for any adverse reactions on the day of the medication error, 04/11/24, and 04/13/24. No
adverse reactions were reported.
Review of the medical record for Resident #13 revealed no documentation related to the medication
administration error on 04/10/24.
Interview on 05/08/24 at 9:21 A.M. with Resident #13 stated she was informed by the nurse that she was
administered a medication in error. Resident #13 stated her lips felt numb, she felt weird, and had some
mood swings after the medication was administered. Resident #13 stated staff observed her for a change
of condition closely for several days. Resident #13 denied any adverse reactions related
(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 6
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
05/08/2024
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 0760
to the allegation.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 05/08/24 at 1:18 P.M. with Director of Nursing (DON) confirmed Resident #13 received a
medication that was not ordered for her on 04/10/24. DON stated Resident #13 did not experience a
change of condition from the medication administration error. DON stated Resident #13 and the physician
were notified of the medication administration error.
Residents Affected - Few
2. Review of the medical record Resident #12 revealed an admission date of 03/16/24 with medical
diagnoses of cellulitis, multiple sclerosis, bipolar disorder, hypertension (HTN), and hypothyroidism.
Review of the medical record for Resident #12 revealed an admission MDS assessment, dated 03/22/24
which indicated Resident #12 was cognitively intact and required moderate staff assistance with toilet
hygiene, bed mobility, and bathing and supervision with transfers.
Review of the medical record for Resident #12 revealed a physician order dated 03/16/24 for Lyrica 150
milligram (mg) capsule, give one capsule by mouth three times a day for neuropathy.
Review of the medical record for Resident #12 revealed a nurse's progress note dated 04/23/24 at 11:55
A.M. which stated Resident #12 was given an extra dose of Lyrica with morning medication pass. No
adverse effects noted, assessment done, vitals taken. The note stated the physician was notified and staff
were to monitor Resident #12 for sedation per the physician.
Review of a facility investigation report, dated 04/23/24, stated Resident #12 was given an extra dose of
Lyrica 150 mg by mouth with morning medication pass. The report stated Resident #12 was alert and
oriented to person, place, time, and situation and was notified of the medication administration error. The
report also stated Resident #12's physician was notified of the medication administration error. The report
indicated the staff monitored Resident #12 for any adverse reactions the day of the medication
administration error, 04/24/24, and 04/25/24. No adverse reactions were reported.
Interview on 05/08/24 at 1:18 P.M. with DON confirmed Resident #12 received an extra dose of Lyrica on
04/23/24. DON stated Resident #12 did not have a change of condition and remained alert and oriented to
person, place, and time. DON stated Resident #12 and her physician were notified of the medication
administration error.
Review of the facility policy titled, Administering Medications, revised April 2019, stated medications are to
be administered in accordance with prescriber's orders. The policy also stated any medication errors are
documented, reported, and reviewed by the Quality Assurance Improvement Performance (QAPI)
committee to inform process changes and or the need for additional staffing.
As a result of the incident, the facility took actions to correct the deficient practice by 05/07/24:
•
On 04/10/24, the DON provided education to Licensed Practical Nurse #9, that was responsible for the
medication error involving Resident #13, on medication administration policy, Five Rights of Medication
Administration, and verification of resident identity using photo identification on Medication Administration
Record (MAR).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365297
If continuation sheet
Page 2 of 6
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
05/08/2024
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 0760
•
Level of Harm - Minimal harm
or potential for actual harm
On 04/10/24, facility physician was notified regarding the medication error for Resident #13 by
DON/designee.
Residents Affected - Few
•
On 04/10/24 A medication observation was completed by DON/designee to ensure there were no like
incidents and no additional variances were identified.
•
On 04/10/24, facility nurses were educated on medication administration, Five Rights of medication
administration, and verification of resident identity via MAR photo by DON/designee.
•
On 04/10/24, DON/designee audited medication administration by observation three times weekly for four
weeks to ensure medications are administered as ordered.
•
On 04/23/24, DON provided education to Registered Nurse (RN) #10, that was responsible for the
medication administration error involving Resident #12, on the Five Rights of medication administration and
medications errors. RN #10 was observed for medication administration prior to the next shift by
DON/designee.
•
On 04/23/24, all resident was assessed for adverse changes and/or sedation with no variances from
baseline by DON/designee.
•
On 04/23/24, Resident #12 was notified of medication administration error by DON/designee. Resident #12
was self-responsible.
•
On 04/23/24, physician was notified of medication administration error involving Resident #12 with no new
orders by DON/designee.
•
On 04/27/24, all licensed nurses received education related to the Five Rights of medication administration
and medication errors prior to or on their next scheduled shift by DON/designee.
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365297
If continuation sheet
Page 3 of 6
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
05/08/2024
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 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 04/27/24, all licensed nurses were administered the medication competency test and passed the test
prior to or on their next scheduled shift by DON/designee.
•
On 04/27/24, all licensed nurses received education related to use of the electronic MAR prior to their next
scheduled shift by DON/designee.
•
On 04/27/24, medication pass observation was completed for all licensed nurses prior to them taking a
medication cart on their next scheduled shift by the DON/designee.
•
Starting on 04/27/24, DON/designee would complete medication pass observation audits five days weekly
on varying shifts. As of 05/07/24, there had been no further medication errors identified.
•
On 04/27/24, results of these audits would be reported to the Interdisciplinary Team (IDT) and on-going
compliance will be maintained through recommendations of the IDT team.
This deficiency represents non-compliance investigated under Complaint Number OH00153184.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365297
If continuation sheet
Page 4 of 6
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
05/08/2024
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 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.
Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's
medical record contained documentation involving a medication error. This affected one (#13) out of four
residents reviewed for medication administration. The facility census was 36.
Findings include:
Review of the medical record for Resident #13 revealed an admission date of 06/06/23 with medical
diagnoses of osteoarthritis, gout, hyperparathyroidism, diabetes mellitus (DM), obesity, end stage renal
disease (ESRD), and atrial fibrillation.
Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment,
dated 03/19/24, which indicated Resident #13 was cognitively intact and required moderate staff assistance
with toilet hygiene and bed mobility and maximum staff assistance with bathing and transfers.
Review of a facility investigation report, dated 04/10/24, stated Resident #13 was inadvertently
administered a dose of Lyrica in error. The report did not indicate the dose of Lyrica that was administered.
The report stated Resident #13 complained of feeling loopy but denied any pain or dizziness. The report
continued to indicate Resident #13 stated she received a white pill in the morning. The report stated
Resident #13's nurse prepared another resident's medications and was interrupted during the task to assist
another staff member. The report stated the nurse locked the prepared medications in the medication cart
and when she returned, she mistakenly administered the wrong medication to Resident #13. Per the report,
Resident #13 remained alert and oriented to person, place, time, and situation and did not have adverse
reaction to the medication administration error. Per the investigation report, the facility staff monitored
Resident #13 for any adverse reactions on the day of the medication error, 04/11/24, and 04/13/24. No
adverse reactions were reported.
Review of the medical record for Resident #13 revealed no documentation related to the medication
administration error on 04/10/24.
Interview on 0508/24 at 1:18 P.M. with Director of Nursing (DON) confirmed the medical record for Resident
#13 did not contain documentation related to the medication administration error on 04/10/24.
Review of the policy titled, Administering Medications, revised April 2019, stated medications are to be
administered in accordance with prescriber's orders. The policy also stated any medication errors are
documented, reported, and reviewed by the Quality Assurance Performance Improvement committee to
inform process changes and or the need for additional staffing.
This deficiency represents non-compliance investigated under Complaint Number OH00153184. This
deficiency represents ongoing noncompliance from the survey dated 04/14/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365297
If continuation sheet
Page 5 of 6
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
05/08/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observation, staff interview, and policy review, the facility failed to follow
infection control procedures during medication administration. This affected one (#14) resident out of the
two residents observed for medication administration. The facility census was 36.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #14 revealed an admission date of 01/22/24 with medical
diagnoses of hypertension, chronic obstructive pulmonary disease, and encephalopathy.
Review of the medical record for Resident #14 revealed a quarterly Minimum Data Set (MDS) assessment,
dated 04/29/24, which indicated Resident #14 had severe cognitive impairment and required maximum
staff assistance with toilet hygiene and bathing, moderate staff assistance with bed mobility and
supervision with eating.
Review of the medical record for Resident #14 revealed physician orders dated 01/22/24 for carvedilol
3.125 milligram (mg) one tablet by mouth every 12 hours; levetiracetam 500 mg one tablet by mouth two
times per day; and senna plus 8.6 mg one tablet by mouth two times per day. The medical record revealed
physician orders dated 01/23/24 for amlodipine besylate 5 mg one tablet by mouth daily; folic acid 1 mg one
tablet by mouth daily; and thiamine 100 mg one tablet by mouth daily.
Observation on 05/08/24 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #153 prepared medications
for administration to Resident #14. LPN #153 was observed to drop amlodipine besylate 5 mg tablet and
carvedilol 3.125 mg tablet onto the medication cart and pick both medications up with her bare hands and
place the medications into the medication cup along with Resident #14's other medications. Observations
revealed LPN #153 then administered medications to Resident #14 and used hand sanitizer upon exiting
Resident #14's room.
Interview on 05/08/24 at 7:33 A.M. with LPN #153 confirmed she picked the amlodipine besylate and
carvedilol tablets off the medication cart with her bare hands and placed the medications into a medication
cup along with Resident #14's other medications. LPN #153 confirmed she then administered the
medications to Resident #14.
Review of the policy titled, Administering Medications, revised April 2019, stated the staff would follow
established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation
precautions, etc.) for the administration of medications as applicable.
This deficiency is based on incidental findings discovered during the course of this complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365297
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the May 8, 2024 survey of SHELBY SKILLED NURSING AND REHABILITATION?
This was a inspection survey of SHELBY SKILLED NURSING AND REHABILITATION on May 8, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SHELBY SKILLED NURSING AND REHABILITATION on May 8, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.