Health inspection·August 28, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to notify a physician of resident's weight loss. This affected one (#13) of two residents reviewed for nutrition. The census was 46. Findings include: Review of medical record for Resident #13 revealed admission date of 07/21/24. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin lymphoma, and stroke. The resident was documented as hospitalized on [DATE] and returned on 08/14/24, and had a second hospitalization on 08/19/24 and returned on 08/23/24. The resident remained in the facility during the survey. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was assessed with moderately impaired cognition, required supervision for eating, and maximum assistance for transfers, bed mobility, and toileting hygiene. Review of Resident #13's electronic medical record revealed the resident weighed 225.0 pounds on 07/22/24. Subsequent weights revealed on 07/29/24 the resident weighed 198.8 pounds, on 08/05/24 the resident weighed 177.5 pounds, on 08/14/24 the resident weighed 185.0 pounds, on 08/17/24 the resident weighed 183.5 pounds, and on 08/25/24 the resident weighed 177.6 pounds. Resident #13 experienced a 21.07 percent (%) weight loss since admission. Further review revealed weight loss was documented on 07/31/24, 08/05/24, 08/14/24, 08/17/24 and 08/25/24 with no indication the physician was notified of the weight loss. Record review of Resident #13's electronic and paper chart revealed no documentation the physician had been informed of weight loss. Interview on 08/28/24 at 11:32 A.M. with Dietician Consultant (DC) #167 revealed she had not seen Resident #13 since the resident's 07/21/24 admission, explaining Resident #13 was at the hospital when she came to the facility on Wednesdays. DC #167 acknowledged she had access to the electronic charting for Resident #13 to review weights and meal intakes. DC #167 stated on 07/31/24 she requested another weight due to the significant change in weight. DC #167 stated she was unaware if the physician had been notified of Resident #13's weight loss explaining she informed the nursing staff of resident weight loss with the expectation they would provide the notification to the physician. Interview on 08/28/24 at 3:12 P.M. with the Administrator and DON revealed Resident #13 had (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 8 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 08/28/2024 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)