Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Logan Health Care Center - Shelby during CMS and state inspections, most recent first.
A resident with swallowing difficulties was not consistently supervised during meals, leading to repeated coughing and a prior choking incident requiring the Heimlich maneuver, while another resident at high risk for falls sustained a major injury after falling from a raised bed due to unclear staff practices and lack of updated fall prevention interventions.
The facility did not consistently update or revise care plans for three residents following significant changes in their conditions, such as falls, new fractures, medication changes, and pressure ulcer status. Staff interviews and record reviews revealed that care plans contained outdated or incomplete information, and immediate interventions were not always documented or implemented after incidents.
The facility did not properly label or date food items in both the kitchen and medication room refrigerators, and lacked policies and procedures for food storage and labeling. Multiple opened or expired food items were found without appropriate dates or resident identifiers, and staff confirmed there was no established process for checking expiration dates or identifying resident food items. These deficiencies affected all residents receiving food services.
Two residents were observed receiving medications at bedside without proper assessment or physician orders for self-administration. Staff left medications with the residents, and records showed no documentation or authorization for self-administration, contrary to facility policy.
A resident admitted with multiple health issues, including a Foley catheter and oxygen use, did not have a complete baseline care plan within 48 hours of admission. The care plan only addressed pain and tissue perfusion, omitting key areas such as catheter care, ADL status, transfer needs, cognitive status, fall risk, and oxygen use. Staff confirmed the care plan was incomplete and did not meet facility policy requirements.
A nurse was observed pre-pouring medications for multiple residents, contrary to facility policy and professional standards, which require preparing and administering medications to one resident at a time. Staff interviews and policy review confirmed that pre-pouring is not permitted, and the nurse acknowledged the error.
A resident admitted with multiple Stage II pressure ulcers experienced worsening of a right buttock ulcer to Stage III due to inconsistent wound assessments, missing documentation, and care plan updates that did not reflect the current wound status or treatment. Staff interviews and record reviews revealed gaps in weekly skin assessments and incomplete documentation of wound debridement, contrary to facility policy.
A resident with limited mobility due to recent hip fractures requested bathroom assistance using the call light. A CNA responded but was unable to assist immediately, resulting in the resident waiting for an extended period and ultimately experiencing incontinence in bed, causing embarrassment and a sense of being unimportant.
The facility failed to prevent, assess, and document the progression of a Stage 4 pressure ulcer for a resident. The resident was readmitted without a sacral pressure ulcer, but by September 2023, a Stage IV pressure ulcer was diagnosed. Weekly skin assessments were not conducted until late September 2023, and consistent assessments only began after a Wound Care PIP was initiated in December 2023. Contributing factors included a lack of pressure-reducing mattresses and poor wound documentation.
The facility failed to ensure proper hand hygiene during wound care for a resident on enhanced barrier precautions and did not maintain wheelchairs in good repair for several residents. Staff did not follow hand hygiene protocols, and multiple wheelchairs had damaged armrests with exposed padding. Maintenance staff was unaware of the facility's preventive maintenance policy, leading to inadequate repairs and cleaning.
The facility failed to ensure an RN was on staff for at least eight consecutive hours a day, seven days a week. A review of the CMS Payroll-based Journal and nursing schedules revealed no RN coverage for eight consecutive hours on multiple days. A staff member confirmed the absence of RN coverage on specific dates and could not explain the lapse.
The facility failed to post the nurse staffing information daily at the beginning of each shift. Observations on two separate days showed no postings, and a staff member confirmed unawareness of the requirement. The facility's policy mandates daily postings in a prominent place.
The facility failed to submit accurate and complete direct care staffing information to CMS, with discrepancies found between the PBJ submissions and the facility's nursing schedules. A staff member admitted the PBJ report was completed but submitted past the deadline, leading to its rejection.
Failure to Provide Adequate Supervision to Prevent Choking and Falls
Penalty
Summary
A deficiency occurred when a resident with a history of swallowing difficulties and choking episodes was not adequately supervised during mealtimes. The resident, who had undergone a swallow study and had a care plan indicating the need for close monitoring, cueing, and food cut into small pieces, was observed coughing, struggling to keep food on her fork, and appearing drowsy during meals without consistent staff assistance. On multiple occasions, staff were not present in the dining room for periods of time, and the resident received cueing from another resident rather than staff. The care plan interventions were not consistently implemented, and there were no new interventions documented when the resident's diet was advanced, despite ongoing issues with coughing and choking. Another deficiency involved a resident at high risk for falls who sustained a fall resulting in major injury. The resident was found with a bruise and a wound after falling from a bed that had been raised to its highest position. Interviews revealed inconsistent accounts regarding how the resident accessed the bed remote, which was typically kept out of reach. Staff were unclear about the circumstances leading to the fall, and there was a lack of documentation and follow-through on new fall prevention interventions. The care plan and post-fall huddle documentation did not specify new actions to prevent future falls, and staff reported not receiving education or updates on fall prevention measures after the incident. Both deficiencies were supported by direct observations, staff interviews, and record reviews, which demonstrated lapses in supervision, inconsistent implementation of care plan interventions, and inadequate communication among staff regarding resident safety needs. The facility failed to ensure a safe environment by not providing adequate supervision to prevent accidents, including choking and falls, for residents identified as being at risk.
Failure to Revise and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were evaluated for effectiveness and revised as needed for three residents. In one case, after a resident experienced a fall resulting in a major injury and was sent to the ER, there were no new immediate interventions implemented, and the care plan was not updated to reflect changes or new strategies to prevent future falls. Staff interviews revealed that while fall interventions were generally communicated through care plans and staff meetings, the specific incident did not prompt a timely update or revision of the care plan, and documentation related to post-fall interventions was left incomplete. Another resident, who had a history of pathological hip fractures and anxiety, had discrepancies in her care plan. The care plan was not updated to reflect a new left hip fracture and continued to list an anti-anxiety medication that had been discontinued months earlier. Staff acknowledged that the care plan should have been revised to reflect these changes, but it was overlooked, resulting in outdated and inaccurate information regarding the resident's current condition and medication regimen. A third resident with a history of pressure ulcers and infection had care plans that were not updated to reflect the current status of their wounds or treatments. Although the infection had been treated effectively, the care plan still included outdated goals and interventions for previous stages of pressure ulcers and did not reflect the most recent changes in the resident's condition. Staff interviews confirmed that care plans should be updated with any significant change, but this was not consistently done.
Failure to Label and Date Food Items and Lack of Food Storage Policy
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in both the kitchen and medication room refrigerators, as well as to develop and implement policies and procedures for food storage and labeling. Observations revealed multiple food items in the kitchen, such as sweetener, ground cloves, sour cream, mozzarella cheese, and liquid whole eggs, that were either missing facility dates, had expired dates, or lacked use-by dates. Staff interviews confirmed the absence of a procedure for checking expiration dates, and staff were unsure of the correct process for discarding expired dairy products. Additionally, in the medication storage room, a refrigerator contained food and drink items for residents that were not labeled with resident identifiers or open dates. Items included a can of beer and bottles of coffee creamer, with staff unable to identify ownership without prior knowledge. A large box of beer cans was also present without resident identifiers. Staff confirmed there was no existing policy for food storage, and a request for such a policy was met with confirmation that none existed. These practices placed all residents at risk for consumption of expired or contaminated food.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to implement a process to identify and assess residents for self-administration of medications for two of fourteen sampled residents. In one instance, a staff member administered oral medications and mixed MiraLAX in juice for a resident, then left the juice with the medication on the bedside table, but could not confirm if the resident was able to self-administer her medications. In another case, a staff member handed medications to a resident, who placed them on the bedside table and stated he would take them later, with the staff member agreeing to return and check on him. Record reviews for both residents showed no physician's order or assessment for self-administration of medications. Staff confirmed that there were no assessments for self-administration for these residents and stated that none of the residents were supposed to be self-administering their medications. Facility policy requires a valid provider order and assessment for self-administration, and medications are not to be kept at bedside without such an order.
Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to complete a comprehensive baseline care plan within 48 hours of admission for a resident with multiple medical conditions, including hypertension, history of falls, confusion, osteoarthritis, frequent urinary tract infections, back pain, an indwelling Foley catheter, and oxygen use. Review of the resident's electronic medical records and baseline care plan revealed that only pain and ineffective peripheral tissue perfusion were addressed, with no focus, goals, or interventions documented for Foley catheter use, ADL status, transfer status, cognitive status, fall status, or oxygen use. Staff interviews confirmed that the baseline care plan was incomplete and did not include all necessary information required for proper care, contrary to facility policy.
Failure to Follow Medication Administration Policy
Penalty
Summary
Facility staff failed to follow professional standards and facility policy regarding medication administration by pre-pouring medications for multiple residents. During an observation, a staff member was found with eight plastic medication cups filled with medications in the medication cart, which she stated was allowed if administered within the hour. However, interviews with other staff and review of the facility's medication administration policy confirmed that pre-pouring medications is not permitted, and the policy requires nurses to prepare and administer medications to one resident at a time. The staff member involved acknowledged her error and stated she was aware that pre-pouring was not allowed.
Failure to Prevent Worsening of Pressure Ulcer Due to Incomplete Assessment and Documentation
Penalty
Summary
A resident was admitted with three Stage II pressure ulcers located on the right buttock, right hip, and left buttock. Over time, the pressure ulcer on the right buttock worsened to a Stage III. Staff interviews revealed that the resident was to be repositioned every two hours and provided with nutritional support, including assistance with eating and increased Glucerna intake after refusing another supplement. Wound care was performed regularly, and the wound was measured weekly by a designated staff member. However, there was inconsistency in wound assessment documentation, with a gap in skin assessments from 11/26/24 through 1/13/25, and requested documentation for debridement notes was not provided. Staff also reported that the wound had become infected and was treated with antibiotics. Review of the resident's care plan and medical records showed discrepancies in the staging and documentation of the wounds, with the care plan not consistently reflecting the current status or treatment of the pressure ulcers. The facility's wound management policy required weekly full assessments and updates to the care plan, but these were not consistently completed or documented. The lack of consistent and timely wound assessments, incomplete documentation, and failure to update the care plan contributed to the worsening of the resident's pressure ulcer from Stage II to Stage III.
Failure to Timely Address Resident's Request for Bathroom Assistance Resulting in Loss of Dignity
Penalty
Summary
A resident with a history of bilateral hip fractures due to prolonged steroid use, and who was currently unable to get out of bed because of a recent left hip fracture, requested assistance to use the bathroom by activating her call light. A CNA responded to the call light, turned it off, and informed the resident that he was busy providing care to another resident but would return to assist her. The resident reported waiting for a prolonged period, during which she was unable to get to the bathroom and subsequently urinated in her bed, leading to feelings of embarrassment and a sense of being unimportant. Facility records confirmed that the CNA acknowledged the resident's request but was unable to assist immediately due to being occupied with another resident and the lack of available staff to help. The incident was documented in a facility-reported incident, which noted that the CNA returned after the resident had already soiled herself. The facility's policy emphasized treating every resident with dignity and respect, fostering an environment where residents feel valued and heard.
Failure to Prevent and Document Progression of Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to prevent, assess, and document the progression of a Stage 4 pressure ulcer for a resident. The resident was readmitted to the facility without a sacral pressure ulcer, but by September 2023, a pressure ulcer of the sacral region was diagnosed. The wound care progress note from November 2023 indicated that the pressure ulcer had been present for nine weeks and was classified as Stage IV. There were no weekly skin or wound assessments until late September 2023, and no assessments were conducted in October or November 2023. Consistent weekly assessments only began after the initiation of a Wound Care Performance Improvement Plan (PIP) in December 2023. Interviews with staff revealed that new management identified wound care as a significant concern and initiated a PIP to address the issue. Contributing factors to the skin concerns included a lack of pressure-reducing mattresses and pads, poor layering of linen and plastic pads under residents, and inadequate wound documentation. The facility's QAPI team implemented immediate interventions, including the use of pressure reduction mattresses and pads, changing to cloth bedding protectors, weekly graphing of wounds, and a consistent wound care protocol. These actions were part of a broader effort to improve wound care processes and reduce the incidence of pressure ulcers among residents.
Removal Plan
- Pressure reduction mattresses and pads
- Change from plastic to cloth bedding protectors for better air flow to skin
- Graphing of wounds
- Wound care protocol for consistency of wound care/nutritional interventions
Infection Control and Wheelchair Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident on enhanced barrier precautions for Multidrug-resistant organisms. During an observation, staff members did not perform hand hygiene between glove changes and between clean and dirty tasks. This was acknowledged by the staff involved, who admitted to knowing the correct procedure but failing to follow it during the observed care. The facility's policy on hand hygiene clearly states that hand hygiene should be performed immediately after the removal of gloves, including between the exchange of dirty to clean gloves. Additionally, the facility failed to provide wheelchairs in good repair for several residents. Observations revealed that multiple wheelchairs had damaged armrests with exposed padding, and one resident's wheelchair had a makeshift repair using a foam pool noodle and dirty tape. Interviews with staff indicated a lack of regular maintenance and cleaning schedules for wheelchairs, and the maintenance staff was unaware of the facility's preventive maintenance policy for wheelchairs. The policy requires weekly checks and repairs for any damaged parts, but this was not being followed. The facility's preventive maintenance policy for wheelchairs was not being implemented, as evidenced by the damaged and unclean wheelchairs observed. Staff interviews revealed that there was no formal record of work orders, and maintenance was done on an ad-hoc basis. The maintenance staff was unaware of the policy, and the night shift staff was responsible for cleaning wheelchairs without a formal schedule or documentation. This lack of adherence to the policy resulted in residents using wheelchairs that were not in good repair and had uncleanable surfaces.
Failure to Ensure RN Coverage for Eight Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on staff for at least eight consecutive hours a day, seven days a week. This deficiency was identified through a review of the CMS Payroll-based Journal, which showed the facility lacked RN coverage for eight consecutive hours on 91 days between 10/1/23 and 12/31/23. Specifically, the facility's nursing schedules indicated no RN coverage for eight consecutive hours on 12/9/23 and 12/10/23. During an interview, a staff member confirmed the absence of RN coverage on these dates and could not provide an explanation for the lapse. The facility's policy requires an RN to provide services for at least eight consecutive hours every 24 hours, seven days a week.
Failure to Post Nurse Staffing Information Daily
Penalty
Summary
The facility failed to post the nurse staffing information on a daily basis at the beginning of each shift. During observations on 5/6/24 at 11:30 a.m. and 5/7/24 at 8:40 a.m., the nurse staffing posting was not found on any wall or public area on the unit. In an interview on 5/8/24 at 8:55 a.m., a staff member stated she was not aware of the requirement for a nurse staff posting and mentioned that her predecessor was also unaware of this requirement. The facility's policy, revised in February 2023, mandates that the Nurse Staffing Sheet be posted at the beginning of each shift in a prominent place readily accessible to residents and visitors.
Inaccurate PBJ Submissions
Penalty
Summary
The facility failed to electronically submit accurate and complete direct care staffing information to CMS, which had the potential to affect all residents. The CMS Payroll-based Journal (PBJ) for the facility indicated concerns for licensed nurse staff on 91 days and a lack of RN coverage for eight consecutive hours each day on 92 days between 10/1/23 and 12/31/23. However, a review of the facility's nursing schedules for the same period showed that the facility did have licensed staff 24 hours a day and RN coverage for eight consecutive hours each day, except on 12/9/23 and 12/10/23. These findings were inconsistent with the PBJ submissions. During an interview, a staff member acknowledged being aware of an issue with the PBJ and admitted that the PBJ report was completed but submitted past the deadline, resulting in its rejection.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Northern Pines Rehabilitation And Nursing | 23.4 mi | ★★★★★ | 27 | 0 |
| Logan Health - Conrad | 23.7 mi | ★★★★★ | 6 | 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 August 2026) and official state health department websites.