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 Diversicare Of Shelby during CMS and state inspections, most recent first.
The facility failed to submit accurate staffing information into the PBJ system for the first quarter of 2024. Frequent call-ins led management to fill in for absent staff, but their hours were not recorded due to payroll system limitations. The facility was also without a payroll person for several months, contributing to the inaccuracies.
The facility failed to maintain window blinds in good repair for a resident's room, resulting in a 12 by 6-inch opening through which the parking lot was visible. Staff typically notified maintenance verbally or by phone, and no work order was entered into the TELS system as required by facility policy.
The facility failed to implement a comprehensive care plan for a resident receiving enteral feeding and did not develop a care plan for a resident on antipsychotic medication. Observations revealed that the feeding pump for one resident was turned off contrary to the care plan, and another resident receiving Seroquel did not have a care plan for the medication, as confirmed by the MDS nurse and Administrator.
A resident with Alzheimer's Disease, Dysphagia, and Gastrostomy status did not receive the prescribed enteral feeding due to conflicting orders on the MAR. Observations showed the feeding pump was off when it should have been on. The DON and RN confirmed the error, which put the resident at risk for weight loss, dehydration, and malnutrition.
The facility failed to accurately complete section P of the MDS for a resident with a wander alert bracelet. The resident was observed wearing the bracelet, but the MDS indicated it was not used. The MDS Nurse confirmed the error, and the DON expected accurate assessments.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing information into the Payroll-Based Journal (PBJ) system for the first quarter of 2024. The report indicates that the facility submitted excessively low weekend staffing data for this period. Interviews with staff, including Licensed Practical Nurses (LPNs) and the Administrator (ADM), revealed that frequent call-ins were a significant issue, and management personnel often filled in for absent staff. However, these management hours were not recorded in the PBJ system because they were salaried employees and did not clock in. The ADM and Director of Nursing (DON) were unaware that they had triggered for low weekend staffing and confirmed that there was no way to add salaried employees' hours to the PBJ system due to corporate payroll system limitations. The Workforce Manager and Human Resources staff confirmed that the payroll system could not accommodate changes to salaried employees' hours, leading to inaccurate staffing data submissions. The facility was also without a payroll person for 4-5 months during the time the low staffing data was reported, which likely contributed to the errors. The ADM acknowledged that she and the Workforce Manager, who were not familiar with payroll, had to manage payroll during this period, further contributing to the inaccuracies in the PBJ submissions.
Failure to Maintain Window Blinds in Good Repair
Penalty
Summary
The facility failed to provide blinds or window coverings in good repair for one of the resident rooms, compromising the resident's right to a safe, clean, comfortable, and homelike environment. During an observation of the room, it was noted that the window blind had broken slats, creating a 12 by 6-inch opening through which the parking lot was visible. Interviews with staff, including a CNA and an RN, revealed that they typically notify the maintenance staff verbally or by phone when they find broken equipment in a resident's room. However, the maintenance staff confirmed that they were not aware of the broken blinds and that no work order had been entered into the TELS system for this issue. The facility's policy requires staff to enter maintenance requests into the TELS system, but it was found that staff have not been consistently following this procedure. The maintenance man verified that he was unaware of the condition of the window blinds in the room and that no work order had been submitted. The Administrator also confirmed that staff usually notify the maintenance man verbally or put maintenance needs on the 24-hour report, rather than entering them into TELS as required by the policy.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident receiving enteral feeding and did not develop a care plan for a resident receiving antipsychotic medication. For Resident #1, the care plan indicated the use of Jevity 1.5 enteral feeding at a specified rate and duration. However, observations revealed that the feeding pump was turned off on multiple occasions, which was confirmed by an LPN and the Director of Nursing. This indicates that the facility did not follow the care plan for the enteral feeding as required. For Resident #54, who was receiving Seroquel for a mood disorder, the facility did not develop a care plan for the antipsychotic medication. The resident was observed to be confused and exhibiting behavioral symptoms. The MDS nurse confirmed that a care plan should have been developed for the antipsychotic medication to guide staff in providing appropriate care. The Administrator also acknowledged that antipsychotic medications should be care planned due to their high-risk nature.
Failure to Administer Enteral Feeding According to Physician's Order
Penalty
Summary
The facility failed to ensure a resident who received enteral nutrition received appropriate treatment and services. Specifically, the facility did not administer the enteral feeding according to the physician's order for one resident. Observations revealed that the resident's feeding pump was turned off during times it should have been on, according to the physician's order. The May 2024 Medication Administration Record (MAR) showed conflicting orders for the resident's enteral feeding, which were both signed off as administered, indicating a failure to follow the correct order. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the resident was not receiving the prescribed enteral feeding due to an error in updating the medical record and a lack of communication among staff. The resident, who was admitted with diagnoses including Alzheimer's Disease, Dysphagia, and Gastrostomy status, was at risk for weight loss, dehydration, and malnutrition due to the improper administration of enteral feeding. The DON acknowledged that the error occurred because the old order was not removed from the MAR when the new order was entered. The RN admitted to following the incorrect order and not questioning the conflicting orders. The facility's Licensed Nursing Home Administrator and the Registered Dietician also confirmed that the resident was at risk for weight loss due to not receiving the prescribed enteral feeding.
Inaccurate Completion of MDS for Resident with Wander Alert Bracelet
Penalty
Summary
The facility failed to accurately complete section P of the Minimum Data Set (MDS) for a resident with a wander alert bracelet. An observation revealed the resident was wearing a wander alert bracelet on her left ankle. However, a review of the resident's quarterly MDS indicated that the wander/elopement alarm was coded as 'not used' during the MDS look-back period. The MDS Nurse confirmed that a data error was made, and the wander alert bracelet was not captured in the assessment. The Director of Nursing (DON) stated that her expectation was for the assessments to be completed accurately by the MDS staff.
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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
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Grove Retirement Home | 6.5 mi | ★★★★★ | 5 | 0 |
| Bolivar Medical Center Ltc | 14.2 mi | ★★★★★ | 0 | 0 |
| Cleveland Community Care Center | 14.3 mi | ★★★★★ | 8 | 0 |
| Delta Rehabilitation And Healthcare Center | 14.5 mi | ★★★★★ | 0 | 0 |
| Greenbough Health And Rehabilitation Center | 17 mi | ★★★★★ | 11 | 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.