Inspection·August 5, 2021

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interviews, and review of facility policy, the facility failed to ensure as-needed anti-anxiety medication had a rationale for continued use past 14 days for one (#18) of six residents reviewed for unnecessary medications. The facility identified 10 residents who were prescribed anti-anxiety medications. The census was 35. Findings include: Review of Resident #18's medical record revealed she admitted to the facility 09/29/20. Her diagnoses included dementia with behavioral disturbance and anxiety. Review of her Minimum Data Set (MDS) assessment dated [DATE], revealed she had a severe cognitive impairment and exhibited behaviors that significantly impacted social interactions. She was dependent on staff for all activities-of-daily-living. She received anti-anxiety medications daily. Review of a physician order dated 06/23/21 revealed Resident #18 was prescribed lorazepam (an anti-anxiety medication) one milligram (mg) each hour as needed for anxiety. Further review of Resident #18's physician orders and medical record lacked evidence a physician documented a rationale for extended use of as-needed anti-anxiety medications. Review of Resident #18's Medication Administration Record (MAR) for June 2021 revealed she received as-needed (PRN) anti-anxiety medications twice 6/23/21, once 6/24/21, 6/28/21, and 06/29/21. Review of Resident #18's Medication Administration Record (MAR) for July 2021 revealed she received as-needed (PRN) anti-anxiety medications once 07/02/21, 07/04/21; twice 07/05/21; once 07/06/21; twice 07/10/21; once 07/11/21-07/13/21, 07/23/21, 07/25/21-07/26/21, 07/30/21; and in August 2021, 08/02/21. Interview on 08/04/21 at 11:29 A.M. with the Director of Nursing (DON) confirmed Resident #18 has received PRN anti-anxiety medication since 06/23/21 without the prescribing physician's rationale for extended use. DON stated the facility lacked a policy that guided staff on the use of anti-anxiety medications. 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: 365331 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 365331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelby Pointe 100 Rogers Lane Shelby, OH 44875 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)