Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Baptist Homes Of Shelbina during CMS and state inspections, most recent first.
A resident with a newly placed right-sided chest port-a-cath did not have appropriate physician orders or documentation for port care following hospital discharge, despite instructions indicating the need for regular flushing. Nursing staff were unaware of the device's status, and records showed no communication with a physician or implementation of care per facility policy, resulting in a deficiency in meeting professional standards.
Staff did not respond promptly to call lights for five residents who required assistance with toileting and transfers, resulting in episodes of incontinence and distress. Despite facility policy outlining call escalation procedures, call light logs showed repeated delays, with some calls unanswered for over 20 minutes. Residents and family members reported long wait times, and leadership was not fully aware of the extent of the delays.
A resident with a newly placed port-a-cath did not have physician orders obtained or implemented for the care and maintenance of the device, despite hospital discharge instructions indicating the need for regular flushing. Nursing staff were unaware or unclear about the presence and care requirements of the port, and there was no documentation of communication with a physician to clarify or obtain necessary orders. Facility leadership confirmed that documentation and awareness of such devices are expected but were not present in this case.
A resident with a history of falls and a hip fracture was injured when a CNA failed to use a gait belt during a transfer, resulting in both the CNA and the resident falling. The resident sustained a skin tear, muscle and ligament tears, and increased pain.
A resident with an order for a Fentanyl patch every 72 hours was found with two patches, leading to an overdose. The resident became unresponsive and required two doses of Narcan before being transferred to the hospital. The facility did not provide a policy for following physician's orders regarding medication administration.
The facility failed to ensure a licensed nursing home administrator was employed and responsible for the management of the facility. The Interim Administrator/HR Director, who did not have an active administrator's license, was handling day-to-day issues. The facility was under a consulting agreement with the corporation, and the Administrator was not a paid employee of the facility, leading to a deficiency in ensuring effective and efficient use of resources for resident well-being.
The facility failed to respond timely to call lights for multiple residents, resulting in episodes of incontinence and unmet needs for assistance. Residents reported waiting for 30 minutes to over an hour for staff to respond, leading to discomfort and incontinence. Additionally, one resident was unable to reach the call light due to it being dropped on the floor by staff, delaying pain medication.
Failure to Obtain and Implement Orders for Port-a-Cath Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care of a resident's right-sided chest port-a-cath following hospital discharge instructions. The resident had a port-a-cath placed on the right side, as documented in the hospital discharge instructions, which specified that the port should be flushed and checked as directed by a healthcare provider, typically every few weeks. However, there was no documentation that staff reviewed or acted upon these instructions, nor was there evidence of communication with a physician to clarify or obtain orders for the care of the new port. Review of the resident's medical records, including the physician order sheets, medication administration records, treatment administration records, and injectable administration history from June 2024 through May 2025, showed no orders for the care or maintenance of the right-sided chest port-a-cath. Interviews with nursing staff revealed a lack of awareness regarding the presence and required care of the port, with some staff believing the port had been discontinued and others recalling that orders for flushing had been removed without clear documentation or rationale. The Director of Nursing and the Administrator both stated that staff should be aware of the presence of such devices and that any communication with physicians regarding their care should be documented, but acknowledged that this had not occurred. Physicians interviewed confirmed that port-a-caths should be flushed regularly to maintain patency and that staff should have sought clarification or orders for care upon the resident's return from the hospital. Despite the presence of the port-a-cath, as observed during the survey, and the hospital's instructions, the facility did not ensure that professional standards of quality were met in managing the resident's device, resulting in a deficiency related to the lack of appropriate physician orders and documentation for port-a-cath care.
Delayed Call Light Response Resulting in Unmet Resident Needs
Penalty
Summary
Staff failed to respond to call lights in a timely manner for five out of six sampled residents, resulting in unmet needs for assistance, particularly with toileting. The facility's own policy required escalating call light responses at specific intervals, but call light logs showed repeated delays, with some calls remaining unanswered for over 20 to 40 minutes. Residents who required substantial or total assistance for toileting, transfers, and ambulation were left waiting, leading to episodes of incontinence and distress. Multiple residents, all cognitively intact except one, reported having to wait extended periods for staff assistance after activating their call lights. These residents had significant medical histories, including recent fractures, use of diuretics, diabetes, heart failure, and mobility limitations requiring wheelchairs or walkers. Several residents described feeling bad or embarrassed after being incontinent while waiting for help, and family members corroborated these delays, noting wait times of up to an hour. The facility's leadership, including the DON and Administrator, acknowledged monitoring call light response times and receiving alerts for excessive delays. However, they were unaware of the full extent of the problem, as they had not identified prolonged response times for all affected residents. Despite daily and weekly reviews of call light logs, the issue persisted, with staff not accommodating residents' needs and preferences for timely assistance, especially for those at high risk for incontinence and falls.
Failure to Obtain and Implement Orders for Port-a-Catheter Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care of a port-a-catheter for one resident following the placement of a new device, as indicated in the hospital discharge instructions. The resident had a port-a-cath placed on the right side of the chest, and discharge instructions specified that the port should be flushed and checked as directed by a healthcare provider, typically every few weeks. However, there was no documentation that staff reviewed or acknowledged these instructions, nor was there evidence of communication with a physician to clarify or obtain orders for the care of the new port. Review of the resident's medical records, including physician order sheets, medication administration records, and treatment administration records from June 2024 through May 2025, showed no orders for the care or maintenance of the right-sided port-a-cath. Interviews with nursing staff revealed confusion and lack of awareness regarding the presence and required care of the resident's port-a-cath. Some staff believed the port had been discontinued, while others recalled previous orders to flush the port but could not recall details or the specific location of the device. There was also no documentation of any staff communication with the physician regarding the discontinuation or ongoing care of the port. Facility leadership, including the DON and Administrator, stated that staff should be aware of the presence of a port-a-cath and that its care should be documented in the medical record. They also indicated that any conversations with physicians regarding the port's care should be documented, but acknowledged that this had not occurred. The resident's primary physician and the facility medical director both confirmed that ports should be flushed regularly to maintain patency and expected staff to obtain appropriate orders upon the resident's return from the hospital if none were provided.
Failure to Use Gait Belt During Transfer
Penalty
Summary
The facility failed to ensure proper use of a gait belt during the transfer and ambulation of a resident who required staff assistance. The resident, who had a history of falls and a left hip fracture, was being assisted to the bathroom by a CNA. During the transfer, the CNA did not use a gait belt as required by the facility's policy. Both the CNA and the resident fell, resulting in the resident sustaining a skin tear, muscle and ligament tears, and increased pain in the left hip. The resident's medical history included a stroke, hemiplegia, and a recent hip fracture. The resident was admitted to the facility with specific discharge orders that included non-weight bearing on the left hand and partial weight bearing on the left leg. The resident's care plan indicated a high risk for falls and required the use of a gait belt for transfers and ambulation. Despite these precautions, the CNA did not use a gait belt during the transfer, leading to the fall and subsequent injuries. Interviews with the resident, CNA, MDS Coordinator, Physical Therapist, and DON confirmed that the gait belt was not used during the transfer. The resident reported increased pain and required further medical interventions, including an MRI and a potential steroid injection. The DON acknowledged that not using a gait belt for a resident needing hands-on assistance could increase the risk of falls, which was evident in this incident.
Resident Found with Two Fentanyl Patches Leading to Overdose
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors. The resident had an order for a Fentanyl patch to be applied every 72 hours for pain control. However, the resident was found with two Fentanyl patches on their skin, which led to the resident becoming nauseated and unresponsive. The resident required two doses of Narcan to become responsive again and was subsequently transferred to the hospital, where it was confirmed that the resident had two Fentanyl patches in place. The facility did not provide a policy for following physician's orders regarding medication administration. The resident's care plan indicated that they had pain primarily in their legs and feet and had a Fentanyl patch applied every three days. The resident's January 2024 Medication Administration Record (MAR) showed the application of the Fentanyl patch but did not document the removal of the previous patch. On the day of the incident, the resident became unresponsive after being assisted to the bathroom and transferred to a recliner. The resident exhibited signs of opioid overdose, including blue lips and agonal gasps, prompting the administration of Narcan and removal of the Fentanyl patch. Interviews with facility staff, a paramedic, and the resident's family member confirmed the presence of two Fentanyl patches on the resident. The Director of Nursing (DON) stated that staff are expected to follow physician's orders and that having two Fentanyl patches could increase the risk of altered mental status and decreased responsiveness. The incident highlights a significant medication error due to the failure to remove the previous Fentanyl patch as per the physician's order.
Failure to Employ Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to ensure a licensed nursing home administrator was employed and responsible for the management of the facility. The facility's census was 59, and the job description for the Administrator outlined various duties, including maintaining the health, welfare, and safety of residents, supervising all departments, and ensuring compliance with regulations. However, the facility had an Interim Administrator/HR Director who did not have an active administrator's license and was not officially appointed by the Board of Directors. Interviews with staff, including the Dietary Manager and the Director of Nursing (DON), revealed that they reported to the Interim Administrator/HR Director for day-to-day issues. The Interim Administrator/HR Director confirmed that she started in the role the previous week after the previous Administrator quit. She also stated that her administrator's license was expired, and she was asked by the corporation to fill in as Interim Administrator. The Corporate VP of Health Care Administration and the facility's Administrator, who was also the corporation's Assistant VP of Operations, confirmed that the facility was under a consulting agreement with the corporation and that the Administrator was not a paid employee of the facility. The Administrator admitted to not being fully aware of the day-to-day activities of the facility and not attending Quality Assurance (QA) or board meetings. The Corporate VP of Health Care Administration was more involved in the facility's operations, visiting the facility multiple times a week. The facility's failure to have a licensed and fully engaged Administrator led to a deficiency in ensuring effective and efficient use of resources to maintain the highest practicable well-being of each resident.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to ensure timely response to call lights for four residents, resulting in episodes of incontinence and unmet needs for assistance. Residents reported waiting for 30 minutes to over an hour for staff to respond to their call lights, which led to incontinence and discomfort. The facility did not have a policy regarding call light response time, and staff were not consistently monitoring call light logs. Resident #1, who was cognitively intact and required moderate assistance for toileting and transfers, experienced multiple instances where call light response times exceeded 30 minutes, leading to episodes of bladder incontinence. Resident #2, who was also cognitively intact and required maximum assistance for transfers and toileting, reported frequent incontinence due to delayed call light responses, with some waits lasting over an hour. Resident #3, with mild cognitive impairment and requiring maximum assistance for transfers and toileting, experienced delays in call light responses, leading to an incident where the resident transferred without assistance and sat in a urine-soaked recliner overnight. Resident #4, who was cognitively intact and required partial assistance for toileting, reported waiting 30 minutes to an hour for staff to respond to call lights, resulting in incontinence. Additionally, Resident #6, who was cognitively intact and experienced frequent pain, was unable to reach the call light due to it being dropped on the floor by staff, leading to a delay in receiving pain medication.
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What surveyors actually found near you
We read the 44 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Shelbina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clarence Care Center | 11.8 mi | ★★★★★ | 7 | 0 |
| Monroe Manor | 15.4 mi | ★★★★★ | 0 | 0 |
| Monroe City Manor Care Center | 16.8 mi | ★★★★★ | 10 | 2 |
| Macon Health Care Center | 22.3 mi | ★★★★★ | 0 | 0 |
| Loch Haven | 24.2 mi | ★★★★★ | 27 | 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.