Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shelby Health And Rehabilitation Center during CMS and state inspections, most recent first.
Homelike Dining Environment Not Maintained: The main dining room was observed empty during lunch on multiple days, and resident council members said they wanted to eat together instead of alone in their rooms. The DM and NHA confirmed the main dining room, along with another dining room, had been closed for meals for months due to short staffing in dining.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Failure to develop comprehensive care plans for two residents. One resident with an indwelling catheter had active orders for catheter care every shift, but the care plan did not include catheter interventions. Another resident with PTSD, dementia, and Parkinson's disease had an active care plan that did not address PTSD, despite the resident and visitor confirming the trauma history and the resident expressing activity preferences. The DON confirmed the catheter care plan should have been created during admission, and the facility's trauma-informed care policy required a trauma-informed care plan for trauma survivors.
A resident with dementia, heart disease, and multiple pressure injuries had delayed repositioning and dressing care. Family reported the resident was left on the back for hours, heel boots were not always replaced, and the LAL mattress intermittently stopped working. During observation, the resident remained in similar positions for extended periods, and the coccyx/buttocks dressing was saturated with drainage or incontinence with slough and bleeding noted. Heel dressings were also observed dated several days earlier than expected.
A resident with an indwelling catheter had the catheter bag repeatedly observed hanging low and touching or resting on the floor, despite staff stating it should remain off the floor and below bladder level. In a separate observation, an LPN and CNA continued care after stool cleanup without changing gloves, and a wound nurse handled gloves without performing hand hygiene first, contrary to the facility’s hand hygiene policy.
Multiple residents were unable to reliably request assistance due to a prolonged call light system outage affecting several units. Residents with physical limitations struggled to use the provided hand bells, and staff had difficulty identifying and responding to calls for help, resulting in significant delays in care. Facility documentation and staff interviews confirmed the lack of a formal plan or training to address the outage, and policies requiring timely response to resident needs were not followed.
A kitchenette cabinet under the sink was found to be water-damaged, wet, and covered with a black, mold-like substance. The Administrator and Maintenance Supervisor were previously unaware of the extent of the issue, which was attributed to seasonal humidity. The unsanitary condition was confirmed through observation and complaint review.
A resident with a history of anemia and GI hemorrhage experienced significant changes in condition, including falls, confusion, and behavioral disturbances. Staff responded by administering Haldol for new behaviors rather than promptly assessing the underlying cause or notifying the physician, despite facility policy requiring such notification. This delay resulted in pain and hospitalization for the resident.
A resident with COPD, acute respiratory failure, impaired cognition, and requiring staff assistance was left unsupervised during a nebulizer treatment. The nurse initiated the treatment and left the room without a documented self-administration assessment or care plan, returning to find the resident unresponsive. Facility policy requires supervision during nebulizer treatments unless a self-medication assessment is completed.
The facility failed to maintain proper infection control practices for three residents in isolation. A nurse entered a resident's room without full PPE, and another resident's PPE caddy was inadequately stocked. An LPN did not perform hand hygiene or use PPE when checking a resident's vitals, and equipment was not cleaned as per protocol.
The facility failed to properly store and label medications for two residents and on three medication carts. A resident had a medicine cup with a red liquid on their dresser, identified as a protein supplement, while another resident had vitamin bottles on their nightstand without being assessed for self-administration. Additionally, a partially dissolved narcotic tablet was found on a medication cart, and several insulin pens lacked labels or dates, violating the facility's medication storage policy.
The facility failed to ensure call lights were accessible to six residents, leading to a deficiency. Observations showed call lights were often out of reach or not easily locatable, confirmed by interviews with residents and family members. The residents had various medical conditions and cognitive abilities, requiring different levels of assistance. The facility's policy on call light accessibility was not followed, as confirmed by staff interviews.
A facility failed to obtain a physician's order for an advance directive upon admission for a resident with cerebral infarction and end-stage renal disease. Despite the facility's policy, no advance directive order was found in the resident's records. Interviews revealed a breakdown in the process, with the admitting nurse responsible for entering the order, but it was not completed.
A facility failed to complete an annual PASARR for a resident with vascular dementia, major depressive disorder, and other conditions. The resident's last PASARR was dated several months prior, and the social worker confirmed that an updated PASARR had not been completed, despite the requirement for annual updates. The facility did not provide a policy related to PASARRs by the end of the survey.
The facility failed to update comprehensive care plans for two residents. One resident exhibited increased refusal of care behaviors, but their care plan was not updated to address these changes. Another resident's care plan contained outdated and conflicting information regarding the use of a neck brace and hand splints. The Director of Nursing confirmed the care plans were not updated to reflect the residents' current conditions.
A resident requiring 1:1 feeding assistance due to visual impairment and recent tube feeding discontinuation was left waiting for help with meals on multiple occasions. Observations showed meal trays untouched for extended periods, and the resident expressed hunger and dissatisfaction with cold food. The facility's policy for meal assistance was not followed, as staff failed to provide timely and continuous support.
A resident with a cervical spinal cord injury was not provided with hand splints as ordered, despite multiple observations of the splints being left on a dresser. The resident reported worsening mobility due to neglect, and staff members were unaware of the need for splints. The facility's policy on medical devices was not followed, resulting in a deficiency.
A facility failed to conduct an initial AIMS assessment for a resident prescribed Seroquel, an antipsychotic medication. The resident, diagnosed with Alzheimer's Disease and Brief Psychotic Disorder, required staff assistance with mobility and was unable to complete a mental status assessment. Despite the requirement for quarterly AIMS assessments for residents on antipsychotics, the facility did not perform this assessment. The DON confirmed the necessity of these assessments, and the facility did not provide a policy on antipsychotic use when requested.
A resident with impaired cognition and specific food dislikes was served a meal containing cucumbers, despite a dietary ticket indicating a dislike for them. The resident, who requires assistance with mobility and has a history of Cerebral Infarction and Dysphagia, reported that the kitchen staff often includes cucumbers despite their preference. The Dietary Manager acknowledged that staff should read and highlight tray tickets to ensure preferences are followed, as per facility policy.
A resident with Dementia and other mental health diagnoses did not receive recommended treatment following a hearing consultation. The consulting physician suggested medication to soften impacted ear wax and a follow-up visit, but these recommendations were not noted or executed. The responsible Social Worker acknowledged that the consult and recommendation were missed in the communication process.
A resident on anticoagulant medication experienced a fall with head trauma and was not promptly transferred to the hospital. Despite visible injuries and increased confusion, the facility opted for neuro checks instead of hospital transfer. The resident later had a seizure and was diagnosed with a traumatic subdural hematoma, leading to their death.
Homelike Dining Environment Not Maintained
Penalty
Summary
The facility failed to maintain a homelike dining environment for seven anonymous resident council residents of eight reviewed. On 4/28/26 at 12:15 PM, the main dining room was observed empty with no residents present during the lunch meal. Similar observations were made on 4/29/26 at 12:20 PM and 4/30/26 at 12:23 PM, when the main dining room was again empty during lunch. Resident council meeting minutes for January 2026 through April 2026 showed residents discussed wanting the dining rooms open so they could eat together instead of eating alone in their rooms. During a group meeting on 4/29/26 at 10:40 AM, eight group members stated they wanted the main dining room reopened so they could eat together again, and they reported it had been closed for meals since the beginning of January 2026 because the facility was short staffed in the dining room. The Dietary Manager confirmed on 04/29/2026 at 12:39 PM that the main dining room and another smaller dining room had been closed since January 2026 due to dining being short staffed. The Administrator also confirmed on 4/29/26 at 1:00 PM that the main dining room had been closed since February 2026 because of short staffing. A facility policy titled Homelike Environment stated residents are provided with a homelike environment and that staff provide person-centered care emphasizing residents' comfort, independence, and personal needs and preferences.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Develop Comprehensive Care Plans for Catheter Care and PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling catheter. R1 was admitted with diagnoses including neuromuscular dysfunction of the bladder, obstructive and reflex uropathy, and unspecified dementia. The most recent MDS showed an indwelling catheter and a BIMS score of 14, indicating intact cognition. On observation, R1's catheter bag was hooked onto the bed in a low position, partially touching the floor and resting on the fall mat. The active orders directed catheter maintenance and care every shift, but the most recent care plan did not include interventions for catheter care. The LPN Manager stated residents with catheters should have a care plan for it, and the DON confirmed R1 should have had a catheter care plan created during admission. The facility also failed to develop a comprehensive care plan for a resident with PTSD. R12 was admitted with diagnoses including PTSD, dementia, and Parkinson's disease. The active care plan did not include interventions for PTSD. R12 was observed independently wheeling back to their room, and during interview stated they enjoyed going to the casino and watching bingo and could use a few more activities they liked. R12 and a visitor confirmed the PTSD was related to R12's military service. The facility policy on trauma-informed care stated residents identified as trauma survivors should receive culturally competent, trauma-informed care and that a trauma-informed care plan should be created to account for the resident's experiences, preferences, and cultural differences.
Delayed repositioning and wound care for resident with multiple pressure injuries
Penalty
Summary
The facility failed to ensure timely repositioning and dressing changes for a resident with dementia, heart disease, and multiple pressure injuries present on admission. The resident required staff assistance for rolling, toileting, transfers, and other activities of daily living, and had a Braden score of 13/23, indicating increased risk for skin breakdown. The active care plan included pressure ulcer care and encouragement/assistance with repositioning. Admission wound documentation identified unstageable pressure injuries to the left heel, right Achilles, coccyx, right gluteus, and left gluteus, and a wound consult later noted that the three buttock wounds had merged into one. Family reported concerns that the resident was not being turned for four hours at a time, that heel boots were not always replaced, that the low air loss mattress intermittently stopped working and had to be unplugged and plugged back in, and that heel dressings had not been changed for several days. During observation, the resident was found lying on the back with the head of bed elevated about 30-45 degrees, with a wedge that did not adequately shift the torso off the back and buttocks. The resident was also observed in similar positioning for extended periods, including remaining in one position for about three and a half hours while staff exited the room and family reported the position had not changed. At one observation, the coccyx/buttocks dressing was saturated with drainage or incontinence, and the wound had blackened slough to most of the base with some bleeding. The surrounding skin was pink and purple and did not fully blanch, and the wound nurse reported it appeared slightly deeper under the edges. The treatment record showed heel dressings were ordered to be changed on the evening shift and the buttocks dressing on the day shift, but family observed dated heel dressings and reported delayed changes. The record also did not show contact to the POA about changes in the care plan and wounds.
Catheter Bag Placement and Hand Hygiene Lapses
Penalty
Summary
The facility failed to ensure indwelling catheter care and hand hygiene infection control practices were followed for one resident with an indwelling catheter. The resident was admitted with diagnoses of neuromuscular dysfunction of bladder, obstructive and reflex uropathy, and unspecified dementia. The most recent MDS indicated the resident had an indwelling catheter, and the BIMS score was 14, showing intact cognition. The resident’s active orders directed catheter care every shift. During multiple observations, the resident’s catheter bag was seen hooked to the bed in a low position and partially touching the floor, with part of the bag leaning onto the fall mat, and later fully on the floor slightly under the bed. Staff interviews stated the catheter bag should be kept off the floor and below bladder level, with a barrier used if the bed is low. In a separate observation, an LPN and CNA provided incontinence care to another resident, cleaned stool, and then continued care without changing gloves. The wound nurse later removed gloves and reached into pockets for additional gloves without first performing hand hygiene, then put on new gloves. The facility’s hand hygiene policy stated hand hygiene is required before and after removing PPE, between direct resident contact, after contact with contaminated objects, and before and after resident care procedures.
Failure to Ensure Timely Resident Care Due to Prolonged Call Light System Outage
Penalty
Summary
The facility failed to meet the timely care needs of six residents due to a prolonged outage of the call light system across multiple units. Residents reported that the call system had been nonfunctional for several weeks to months, and they were instead provided with small hand bells to request assistance. Several residents expressed that the hand bells were difficult to use, especially for those with physical limitations such as numbness in the hands or the need for bilateral wrist and hand splints. In some cases, residents were unable to locate their hand bells or could not bring them into the bathroom, leaving them unable to call for help when needed. Observations and interviews revealed that staff were often unable to hear or identify which resident was ringing a hand bell, leading to significant delays in response times. One resident reported waiting an hour and a half for assistance to use the restroom, while another was observed ringing their bell multiple times without staff response. Staff confirmed the difficulty in distinguishing the source of the bell sounds and noted that they had to physically check each room to determine who needed help. There was also a lack of specific training or program changes implemented to address the outage, and staff were not provided with formal guidance on how to monitor or assist residents during this period. Facility documentation showed ongoing issues with the call light system, including multiple units being affected and no clear timeline for repair. Review of policies indicated that the facility was required to provide accessible call lights and respond in a timely manner, but these standards were not met during the outage. Quality Assurance meeting agendas and education records did not reflect a formal action plan or targeted education regarding the outage, and invoices confirmed ongoing repair attempts without resolution.
Unsanitary Kitchenette Cabinet Due to Water Damage and Mold
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchenette located off the main dining room. On observation, the cabinet under the sink was found to have water-damaged doors, with the particle board swollen and warped from previous water exposure. The bottom shelf of the cabinet was wet, and a black, mold-like substance was present on the surface. The Administrator was unaware of the issue prior to the observation, and the Maintenance Supervisor indicated that the problem was seasonal, related to warmer weather and humidity. These findings were based on a complaint intake and direct observation, confirming the presence of unsanitary conditions in the kitchenette area. No information about specific residents or their medical conditions was provided in relation to this deficiency.
Failure to Promptly Assess and Notify Physician for Acute Change in Condition
Penalty
Summary
The facility failed to promptly identify, assess, and notify a physician regarding an acute change in condition for a resident, resulting in pain and hospitalization. The resident, who was admitted with acute posthemorrhagic anemia and gastrointestinal hemorrhage and had an intact cognitive status on admission, experienced several significant changes in condition, including a fall, confusion, dizziness, low oxygen saturation, and behavioral changes such as combativeness and self-injurious actions. Despite these changes, the facility's response included administering Haldol for new behaviors rather than immediately evaluating the underlying cause or notifying the physician in a timely manner. Documentation revealed that the resident had a foley catheter bag full of blood, experienced multiple falls, and displayed a marked change from their baseline mental status. Staff interviews indicated that these behaviors were not typical for the resident, and there was uncertainty about whether the physician or DON had been notified about the significant findings, such as the blood in the foley bag and the resident's confusion after falls. The facility's policy required notification of the physician and designated representative for significant changes in status, but this was not consistently followed, leading to a delay in appropriate medical evaluation and intervention.
Failure to Supervise Resident During Nebulizer Treatment
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, impaired cognition, and requiring staff assistance for bed mobility and transfers, was left unsupervised during a nebulizer treatment. The resident had complained of shortness of breath, and a nurse initiated a nebulizer treatment but left the room, returning ten minutes later to find the resident unresponsive with the face mask off. There was no documentation of a self-administration of medication assessment or care plan in the resident's medical record. Facility policy requires staff to remain with a resident during nebulizer treatments unless a self-medication assessment has determined the resident can safely self-administer. The Director of Nursing confirmed that staff are expected to stay with residents during such treatments or ensure someone else is present if they must leave. The lack of a completed self-administration assessment and the absence of supervision during the nebulizer treatment led to the deficiency.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices for three residents in isolation and precautions. For one resident, a nurse entered the room without donning the required personal protective equipment (PPE) despite clear signage indicating the need for gloves, mask, and gown. The nurse only wore gloves while disconnecting the resident's IV machine, which was against the facility's infection control expectations. This resident had impaired cognition and required assistance with mobility and transfers. Another resident's PPE caddy was consistently found to be inadequately stocked, lacking essential items such as gloves, gowns, and face masks. This resident required assistance for all activities of daily living, including catheter care. Additionally, a Licensed Practical Nurse (LPN) failed to perform hand hygiene and did not use PPE when entering a resident's room to check blood pressure and glucose levels. The LPN also did not clean the equipment after use, contrary to the stated cleaning protocol. The facility's equipment cleaning policy was requested but not provided by the end of the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents and on three medication carts. For one resident, a medicine cup filled with a red liquid was found on their dresser, which the resident believed to be cough medicine. However, the Unit Nurse Manager identified it as a protein supplement and discarded it. The resident's medical record indicated they were moderately cognitively impaired and required maximum assistance for most activities of daily living. Another resident was found with bottles of Vitamin C and Vitamin B-12 on their nightstand, which they claimed to self-administer daily. The Director of Nursing confirmed that this resident had not been assessed for self-administration of medications, indicating a lapse in protocol. Additionally, during a review of medication carts, a partially dissolved narcotic tablet was found in a medicine cup, which had been spat out by a resident. The LPN explained they were waiting for a second nurse to dispose of it properly. Furthermore, several KwikPen Humalog insulin pens were found without labels or dates on two different medication carts. The facility's policy requires accurate labeling and dating of medications, which was not adhered to in these instances. The Director of Nursing confirmed that wasted narcotics should be disposed of immediately with the presence of two licensed nurses, a procedure that was not followed in this case.
Deficiency in Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were accessible to six residents, leading to a deficiency in call light accessibility. Observations revealed that residents' call lights were often out of reach or not easily locatable. For instance, one resident's call light was found on their wheelchair, out of reach, while another resident's call light was located in a shut dresser drawer, making it inaccessible. Additionally, a resident's call light was observed hanging underneath their bed, out of sight and reach. Interviews with residents and family members confirmed these observations, indicating that the issue was recurrent. The residents involved had various medical conditions, including cellulitis, heart failure, sepsis, paroxysmal atrial fibrillation, epilepsy, asthma, Alzheimer's disease, and anxiety. Their cognitive abilities ranged from moderately impaired to intact, with some residents requiring maximum assistance for activities of daily living. The facility's policy on call light accessibility, which mandates that call lights be within reach of residents, was not adhered to, as confirmed by interviews with staff, including a Licensed Practical Nurse and the Nursing Home Administrator.
Failure to Obtain Advance Directive Order Upon Admission
Penalty
Summary
The facility failed to obtain a physician's order for an advance directive upon admission for a resident with cerebral infarction and end-stage renal disease. The resident, identified as having impaired cognition with a Brief Interview for Mental Status score of 8/15, required staff assistance with bed mobility and transfers. Despite the facility's policy requiring the entry of a physician's order for code status upon admission, no such order was found in the resident's medical records. Interviews with facility staff revealed a breakdown in the process of entering advance directive orders. The social worker indicated that the admitting nurse is responsible for entering the code status order, which is then reviewed at the care conference. However, the Director of Nursing was unaware of why the order was not completed for this resident. The facility's policy specifies that a physician's order for Full Code status should be entered into the electronic health record system, but this was not done for the resident in question.
Failure to Complete Annual PASARR for Resident
Penalty
Summary
The facility failed to complete an annual Preadmission Screen and Resident Review (PASARR) for a resident reviewed for PASARR screening. The resident, identified as R121, was observed on March 3, 2025, and had been admitted with diagnoses including vascular dementia, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. The resident's medical record showed a Minimum Data Set (MDS) assessment with a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment, and a Patient Health Questionnaire score of 9, indicating severe depression. The last PASARR was dated October 8, 2023, and during an interview on March 5, 2025, the social worker confirmed that an updated PASARR had not been completed, acknowledging that it should be updated annually. The facility did not provide a policy related to PASARRs by the end of the survey.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and updated for two residents, R51 and R89. For R51, the medical record indicated increased behaviors of refusal of care and assistance, such as refusing bathing and assistance weekly during February 2025. Despite these changes, the behavioral care plan initiated in July 2024 was not reviewed or updated to address these increased behaviors. Social Worker C confirmed that no updates were made to the care plan to address the recent behaviors. For R89, the care plan contained outdated and conflicting information. R89, who receives nutrition via tube feeding and is supposed to have hand splints applied, had a care plan that still included a neck brace, which was discontinued after a post-operative appointment in early February. The Therapy Director confirmed the neck brace should have been removed from the care plan, and there was confusion regarding the application of hand splints due to conflicting information. The Director of Nursing confirmed that R89's care plan was not updated to reflect the current condition, and a facility policy addressing care plans was not provided by the completion of the survey.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident, identified as R142, who required 1:1 feeding assistance due to visual impairment and recent discontinuation of tube feeding. On multiple occasions, R142's meal trays were observed untouched for extended periods, indicating a lack of timely assistance. On March 3, 2025, R142's lunch tray remained untouched for over an hour, and the resident expressed hunger and the need for assistance. Physical Therapy staff noted the resident had not eaten, and R142 later reported that the food was cold by the time assistance was provided, resulting in minimal consumption. Further observations on March 5, 2025, revealed similar issues with breakfast, where R142 waited for assistance to finish their meal. Despite being identified as needing 1:1 feeding assistance, the resident was left waiting, and staff were not immediately responsive to their needs. The Director of Nursing acknowledged that staff should not leave trays unattended and should provide continuous assistance until the resident finishes eating. The facility's policy mandates that residents receive meal assistance according to their individual needs and care plans, which was not adhered to in this case.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to apply hand splints as ordered for a resident, identified as R89, who was observed multiple times lying in bed with their arms folded and hands on their chest, while the prescribed hand splints remained on the dresser across the room. R89, who has an unspecified injury at the cervical spinal cord level and intact cognition, reported that they were supposed to wear the hand splints but that no one ever applied them. The resident expressed that their condition had worsened due to neglect, as they were initially able to move their arms and hands more than they can now. The physician's orders and care plan indicated that the hand splints were to be worn at night and removed in the morning, yet staff members, including an LPN and a CNA, were unaware of the resident's need for hand splints. The Therapy Director confirmed that the splints should be applied at night by nursing staff, as restorative aides are not present during that time. The Director of Nursing acknowledged that applying hand splints is a collaborative effort between nursing and therapy, but the facility's policy on accommodating residents with medical devices was not followed, leading to the deficiency.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to conduct an initial Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was prescribed an antipsychotic medication, Seroquel, once daily. The resident, who was admitted with diagnoses of Alzheimer's Disease and Brief Psychotic Disorder, was unable to complete a mental status assessment and required staff assistance with mobility. Despite the requirement for quarterly AIMS assessments for residents on antipsychotics, the facility did not perform this assessment for the resident. During an interview, the Director of Nursing acknowledged that nursing staff should complete AIMS assessments quarterly for residents on antipsychotics, regardless of psychiatric follow-up. Additionally, the facility failed to provide a policy related to antipsychotic use upon request by the surveyors.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as R142, who was reviewed for food preferences. On March 3, 2025, R142's lunch tray was observed with cucumbers in the side salad, despite a dietary ticket indicating a dislike for cucumbers, highlighted in pink. R142 expressed that they do not like cucumbers and that the kitchen staff often includes them despite their preference. R142 was admitted to the facility with diagnoses of Cerebral Infarction and Dysphagia and had an impaired cognition with a Brief Interview for Mental Status score of 10/15. The resident also required staff assistance with bed mobility and transfers. The Dietary Manager, DM Q, stated that dietary staff should read and highlight tray tickets to ensure preferences are seen, and floor staff should check trays before serving them to residents. The facility's policy on Food Preferences and Select Menus states that meals should accommodate resident allergies, intolerances, and food preferences.
Failure to Implement Consultant's Recommendations for a Resident
Penalty
Summary
The facility failed to ensure that a resident received the recommended treatment following an outside consultation. The resident, who was admitted with diagnoses including Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, was evaluated by a consulting hearing service. The consulting physician was unable to remove impacted ear wax and recommended a medication to soften the wax, with a follow-up visit in 1-3 months. However, this order was not noted or carried out. An interview with the responsible Social Worker revealed that the process for communication involves the Social Worker receiving the completed consult/report, reviewing the documentation, and requesting appropriate orders from the physician or setting up a follow-up appointment. The Social Worker admitted that the consult and the recommendation were missed.
Failure to Ensure Timely Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to ensure a comprehensive nursing assessment and timely acute care emergent hospital transfer for a resident who sustained a fall with head trauma and bleeding while on anticoagulant medication. The resident, who had quadriplegia and atrial fibrillation, was found on the floor with a bruise on the right eyelid, a superficial scrape on the right forearm, and a skin tear. Despite these injuries and the resident's confusion, the decision was made to conduct neuro checks instead of transferring the resident to the hospital. The resident's medical record indicated that they were on Eliquis, a blood thinner, and had a history of moderate cognitive impairment. After the fall, the resident exhibited increased confusion, which was attributed to a urinary tract infection. The facility's staff, including a nurse practitioner, assessed the resident and decided against hospital transfer, despite the resident's unwitnessed fall and visible head injury. The facility's policy did not specifically address unwitnessed falls for residents on anticoagulant medication. Later, the resident experienced a seizure and was transferred to the hospital, where they were diagnosed with a traumatic subdural hematoma. The resident's condition deteriorated, leading to their death four days later. The facility's failure to promptly transfer the resident to a higher level of care after the fall and head injury, especially given the resident's anticoagulant use, was a significant deficiency in their care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shelby Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shelby Crossing Health Campus | 0.4 mi | ★★★★★ | 0 | 0 |
| Lakeside Manor Nursing And Rehabilitation Center | 1.1 mi | — | 12 | 0 |
| Medilodge Of Shoreline | 1.5 mi | ★★★★★ | 8 | 0 |
| Regency Manor Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 9 | 0 |
| Regency At Shelby Township | 2.7 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.