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, (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: 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 10/12/2023 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)