Health inspection·October 12, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure call lights were within reach and accessible for residents. This affected four residents (#02, #30, #14, and #15) of 38 residents reviewed for call light placement. Residents Affected - Some Findings Include: 1) Record review for Resident #02 revealed the resident was admitted on [DATE] with diagnoses that included, but not limited to, major depressive disorder, chronic obstructive pulmonary disease (COPD), schizophrenia, and personality disorder. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 07/21/23 for Resident #02, revealed the resident had severely impaired cognition and required extensive assistance of one staff member for mobility, transfer, and toilet use. Observation and interview of Resident #02 on 10/10/23 at 9:25 A.M., revealed the resident was lying in bed and his call light was lying on the floor under the bed. Resident #02 stated that she used the call light when she could find it. The call light was noted to be out of reach of Resident #02. Interview with Assistant Director of Nursing (ADON) #333 on 09/25/23 at 10:09 A.M. verified Resident #02's call light was out of reach and the resident couldn't access her call light. 2) Record review for Resident #30 revealed the resident was admitted on [DATE] with diagnoses that included, but not limited to, vascular dementia, wasting and atrophy, anxiety, and major depressive disorder. Review of the most recent MDS assessment 3.0 dated 07/28/23 for Resident #30, revealed the resident had severely impaired cognition and required extensive assistance of two staff for mobility, transfer, and toilet use. Observation of Resident #30 on 10/10/23 at 9:32 A.M., revealed the resident was lying in bed and his call light was behind the dresser. The call light was noted to be out of reach of Resident #30. Interview with Licensed Practical Nurse (LPN) #340 on 10/10/23 9:32 A.M., verified Resident #30's call light was out of reach and the resident couldn't access the call light. 3) Record review for Resident #14 revealed the resident was admitted on [DATE]. Diagnoses included schizoaffective disorder, restlessness and agitation, depression, mood disorder, dysphagia, Page 1 of 6 365331 365331 10/12/2023 Shelby Pointe 100 Rogers Lane Shelby, OH 44875

F 0558 difficulty in walking, unspecified convulsions, and muscle weakness. Level of Harm - Minimal harm or potential for actual harm Review of the fall risk assessments dated 08/05/23, 08/15/23, 10/04/23, and 10/09/23 for Resident #14 revealed the resident was at high risk for falls. Residents Affected - Some Review of the quarterly MDS assessment 3.0 dated 09/13/23 for Resident #14, revealed the resident was cognitively impaired and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the plan of care dated 08/14/23 for Resident #14, revealed the resident was at risk for falls. Interventions included anti-tippers to wheelchairs, re-educate resident to use call light, and call light in reach when in room. Observation on 10/10/23 at 9:32 A.M., revealed Resident #14 was lying in bed and his call light was not within reach. The call light was located behind a nightstand which was centrally located against a wall of the room and not near the resident. During an interview with ADON #333 at the same time, verified Resident #14's call light was not within reach and should have been. Review of the active October 2023 physician orders for Resident #14 revealed an order for encouraging the resident to use call light for staff assistance with activities of daily living. 4) Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, vascular dementia, restlessness and agitation, depression, muscle weakness, and difficulty in walking. Review of the MDS assessment 3.0 dated 08/16/23 for Resident #15, revealed the resident was cognitively impaired and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of a fall risk assessment dated [DATE] for Resident #15, revealed the resident was at high risk for falls. Observation on 10/10/23 at 9:25 A.M. revealed Resident #15 was lying in bed and his call light was not within reach or near the bed. The call light was located on top of a nightstand which was located on the other side of a curtain which was used to divide the room. During an interview with the ADON #333 at the same time, verified Resident #15's call light was not within reach and should have been. Review of the undated facility policy titled Answering the Call Light, revealed staff would ensure that resident call lights were accessible to the resident when in bed, from the toilet, from the shower or bathing facility from the floor. 365331 Page 2 of 6 365331 10/12/2023 Shelby Pointe 100 Rogers Lane Shelby, OH 44875

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to submit a new Pre-admission Screening and Resident Review (PASARR) when a resident received a new diagnosis of schizoaffective disorder. This affected one resident (#27) of three residents reviewed for PASARR. The facility census was 38. Findings include: Record review for Resident #27, revealed the resident was admitted to the facility on [DATE]. Diagnoses included other psychoactive substance abuse and alcohol abuse. Further review of the medical record revealed a new diagnosis of schizoaffective disorder which was added for Resident #27 on 11/16/21. Review of the annual Minimum Data Set (MDS) assessment 3.0 dated 07/01/23 for Resident #27, revealed the resident was cognitively impaired and had verbal behavioral symptoms directed toward others. Review of the electronic and paper medical records for Resident #27 revealed no evidence a new PASARR was completed when the resident received a new diagnosis of schizoaffective disorder. Interview on 10/11/23 at 11:51 A.M. with Social Service Designee (SSD) #349 verified a new PASARR should have been completed when Resident #27 was diagnosed with schizoaffective disorder. Interview on 10/12/23 at 7:45 A.M. with the Administrator verified Resident #27 should have a new PASARR completed/submitted upon receiving a new mental health diagnosis and did not. 365331 Page 3 of 6 365331 10/12/2023 Shelby Pointe 100 Rogers Lane Shelby, OH 44875

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, interviews and record reviews, the facility failed to serve food at the proper portion size to meet the resident's nutritional needs. This affected seven residents (#4, #5, #8, #12, #14, #21 and #26) who the facility identified as receiving mechanical soft diets. The facility census was 38. Findings include: Observation of tray line on 10/12/23 at 11:45 A.M. revealed [NAME] #342 was scooping up the cold chicken salad into her gloved hand and placing the chicken salad on the lettuce situated on the plates. Interview with [NAME] #342 at the same time indicated she did not know the correct portion size for the chicken salad because the daily spreadsheet was in Dietary Manager (DM) #351's office. [NAME] #342 verified she was using her gloved hand to scoop out the chicken salad and plate it. Interview with DM #351 on 10/12/23 at 11:50 A.M. revealed the daily spreadsheet was in his office. DM #351 verified the mechanical soft diets should have received four ounces of cold chicken salad. DM #351 verified [NAME] #342 was plating the mechanical soft foods with her gloved hand and without an appropriate four-ounce food scooper. 365331 Page 4 of 6 365331 10/12/2023 Shelby Pointe 100 Rogers Lane Shelby, OH 44875

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews and contractor interviews, the facility failed to ensure the low temperature dishwasher was functioning properly to sanitize the dishes and utensils. This had the potential to affect all 38 residents who the facility identified as receiving meals from the facility. The facility also failed to handle, prepare, distribute, and serve food in accordance with professional standards for food service safety. This affected seven residents (#4, #5, #8, #12, #14, #21 and #26) who the facility identified as receiving mechanical soft diets. The facility census was 38. Findings include: 1) Observation of the low temperature dishwasher on 10/10/23 at 8:47 A.M. with Dietary Manager (DM) #351, revealed DM #351 attempted to get a reading of the sanitizer on the test strips and the strips did not register any parts per million (ppm) to ensure concentration of the sanitizer was correct. DM #351 indicated the dishwasher should be registering at 50 PPM on the test strips for proper sanitation. DM #351 verified the findings at time of observation. Observation and interview on 10/12/23 at 11:11 A.M. with Chemical Company Technician (CCT) #422, revealed the sanitizer line running to the dishwasher had a hole in it and the tubing was pinched off restricting the flow of sanitizer going into the dishwasher. CCT #422 stated that the dish machine should register at 50 ppm for sanitization and when he arrived, the dishwasher was registering at zero PPM. 2) Observation of tray line on 10/12/23 at 11:45 A.M. revealed [NAME] #342 was scooping up the cold chicken salad into her gloved hand and placing the chicken salad on the lettuce situated on the plates. Interview with [NAME] #342 at the same time indicated she did not know the correct portion size for the chicken salad because the daily spreadsheet was in DM #351's office, so she used her gloved hand. [NAME] #342 verified she was using her gloved hand to scoop out the chicken salad and plate it. Interview with DM #351 on 10/12/23 at 11:50 A.M. verified [NAME] #342 was plating the mechanical soft foods with her gloved hand and should have used an appropriate four-ounce food scooper. 365331 Page 5 of 6 365331 10/12/2023 Shelby Pointe 100 Rogers Lane Shelby, OH 44875

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff and resident interviews, the facility failed to ensure resident's equipment was clean and in good repair. This affected three residents (#07, #08 and #30) of the 38 residents observed during the initial screening process. The census was 38. Residents Affected - Few Finds Included: 1) Observation of Resident #08 on 10/10/23 at 11:08 A.M. revealed the resident's wheelchair was dirty with grime and crumbs around the wheels, foot pedals, and seat cushion. Interview with Resident #8 at the same time, revealed his wheelchair had never been cleaned and it would be nice if it was clean. 2) Observation of Resident #07 on 10/10/23 at 11:29 A.M. revealed the resident wheelchair was dirty with dried food, liquid and grime on wheelchair wheels, foot pedals and the arm rests and the left arm rest was torn. Interview with Resident #7 at the same time, revealed her wheelchair had not been cleaned for a long time. 3) Observation of Resident #30 on 10/12/23 at 8:10 A.M. revealed the resident's wheelchair was dirty with dried food and covered in grime on wheels, cushion, and the wheelchair frame. Interview with Maintenance Director #304 on 10/12/23 at 8:15 A.M. verified the above concerns related to unkept resident's wheelchairs. Interview with the Administrator on 10/12/23 at 8:25 A.M. revealed there was no formalized plan for cleaning the resident's wheelchairs and there was no log of when the resident's wheelchairs had been cleaned or were scheduled to be cleaned. The Administrator stated there was no policy for cleaning resident wheelchairs. 365331 Page 6 of 6