Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Shelby Oaks Post Acute during CMS and state inspections, most recent first.
Failure to notify the RP of a resident's hospital transfer. Facility policy required notification of the resident, attending physician, and resident representative when a resident's condition changed or transfer was needed. A resident with encephalopathy, aphasia, heart failure, and diabetes was nonverbal and severely impaired for daily decision making, but the record had no documentation that the RP was told when the resident was transferred to the hospital for shortness of breath and acute hypoxic respiratory failure. The DON confirmed the RP should have been notified and the facility could not provide proof of notification.
Enteral feeding care was not provided as ordered for two residents with PEG tubes. One resident had intact cognition and the other had severely impaired cognition, and both had physician-ordered tube feedings with water flushes. During observation, the feeding containers had no infusion rate on the label and the water flush bags were missing required labeling such as rate, date, and resident name. The DON confirmed the missing labeling, and an RN stated the facility used standard practice for hanging and administering enteral feeding.
Infection Control Failures During Resident Care and Medication Administration: Staff failed to follow hand hygiene and PPE practices during incontinent care, wound care, medication administration, and catheter care. An LPN and CNA did not wear gowns when required for EBP, handled soiled items and wound care without proper PPE, and changed gloves without hand hygiene. An LPN also placed medications directly on an over-bed table without a barrier and did not clean hands between glove changes while administering eye drops, a patch, and oral meds to a resident with severe cognitive impairment.
Two cognitively impaired residents experienced multiple injuries of unknown origin, including head trauma, bruising, and fractures, without proper assessment, documentation, or investigation by staff. Facility staff failed to notify the physician or state agencies, and did not follow required protocols for reporting and investigating abuse or neglect. Interviews revealed that staff did not consistently perform head-to-toe assessments or complete occurrence reports, and the DON did not initiate investigations, resulting in Immediate Jeopardy for the facility.
The facility failed to promptly report and document injuries of unknown origin for two residents with cognitive impairment and high care needs. Required occurrence reports, assessments, and detailed documentation were not completed, and the injuries were not reported to State Agencies as mandated by facility policy. Interviews with the DON and Administrator confirmed insufficient reporting and documentation.
Failure to Notify RP of Hospital Transfer
Penalty
Summary
The facility failed to notify the provider and the resident representative of a resident's change in condition and failed to obtain stat labs and transfers for 1 of 4 sampled residents reviewed for notification of change. Facility policy titled, "Change in a Resident's Condition or Status," stated that the facility notifies the resident, the attending physician, and the resident representative of changes in the resident's medical or mental condition, and that a nurse will notify the resident's representative when it is necessary to transfer the resident to a hospital or treatment center. Resident #76 was admitted with diagnoses including encephalopathy, aphasia, heart failure, and diabetes, and the quarterly MDS indicated the resident was severely impaired for daily decision making. The medical record contained no documentation that the resident's transfer to the hospital on 5/9/2025 was reported to the Responsible Party. The hospital H&P documented that the resident, who was nonverbal, presented with shortness of breath and acute hypoxic respiratory failure, with findings concerning for pneumonia versus volume overload/effusion. During interview, the DON stated that the RP should have been notified and confirmed the facility could not provide documentation that the RP had been informed of the transfer.
Enteral Feeding Bags Not Properly Labeled
Penalty
Summary
Care for residents with enteral feedings was not provided as ordered for 2 of 2 sampled residents with PEG tube feedings. Resident #6 had diagnoses including Gastrostomy Status, Aphasia, Cerebral Infarction, and Dysphagia, and the quarterly MDS showed a BIMS score of 14, indicating intact cognition. Physician orders directed Vital Peptide 1.5 at 55 mL/hr via PEG tube with continuous feeding and automatic water flushes, but during observation the enteral feeding was hanging with no infusion rate on the label and the water flush solution bag was not labeled with a rate, date, or resident's name. Resident #54 had diagnoses including Gastrostomy Status, Dysphagia, and Abnormal Weight Loss, and the quarterly MDS showed a BIMS score of 00, indicating severely impaired cognition. Physician orders directed Glucerna 1.5 at 50 mL/hr via gastrostomy tube with water flushes, but observation showed the enteral feeding being administered with no rate on the bottle and the water flush solution bag not labeled with a rate, date, or resident's name. The DON confirmed for both residents that the feeding and water flush bags lacked the required labeling, and stated the facility did not require the resident's name on the enteral feeding or water bottle, while Quality Service RN E stated the facility used standard of practice for hanging and administering enteral feeding.
Infection Control Failures During Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed when staff did not use proper PPE, did not use barriers during medication administration, and did not perform hand hygiene during incontinent care, wound care, medication administration, and catheter care. Facility policies reviewed stated that hand hygiene is the primary means to prevent the spread of infections, that hand hygiene is required before preparing or handling medications, after contact with intact skin, after handling used dressings or contaminated equipment, and after removing gloves, and that gloves do not replace hand hygiene. The facility’s Enhanced Barrier Precaution policy stated that gown and glove use is required during high-contact resident care activities such as hygiene, changing briefs, wound care, and care for residents with wounds or indwelling medical devices. Resident #54 was admitted with diagnoses including gastrostomy status, dysphagia, and abnormal weight loss, had severely impaired cognition, and had a sacral wound and feeding tube. The resident had orders for Enhanced Barrier Precautions due to an indwelling device and open wound, and for daily sacral wound care. During observation in the resident’s room, a CNA wore gloves but no gown while the resident had a bowel movement and a soiled sacral wound dressing was present. The CNA removed soiled gloves and exited without hand hygiene. An LPN entered with gloves but no gown, and the CNA returned without a gown and began incontinent care. The LPN assisted with incontinent care and wound care, removed a soiled dressing, cleaned the wound area, handled soiled linen, and later changed gloves without hand hygiene. The CNA handled soiled linen and gloves, placed them in bags, and took the bags into the hallway without hand hygiene, then separated the soiled items in the hallway with ungloved hands before going to another resident’s room to wash hands. Resident #77 was admitted with diagnoses including metabolic encephalopathy, dementia, cognitive communication deficit, and muscle weakness, and had severe cognitive impairment. During medication administration, an LPN placed eye drop containers and oral medications directly on the over-bed table without a barrier. The LPN donned gloves to administer the first eye drops, removed the gloves, and did not perform hand hygiene before putting on another pair of gloves for the second eye drops. The same pattern occurred before placing a medicated patch and before administering oral medications. Resident #75 was admitted with diagnoses including urinary tract infection and presence of urogenital implants, had moderately impaired cognition, and had an order for Enhanced Barrier Precautions related to an indwelling urostomy tube. During observation, an LPN handled the urine-filled catheter bag without a gown, placed a cover over the bag with gloved hands, removed gloves, and then handled the resident’s food tray lid without hand hygiene. The DON stated staff should wear gloves and an isolation gown for Enhanced Barrier Precautions and should wash hands in between glove changes during medication administration, and acknowledged nurses should use barriers on tables in resident rooms during medication administration.
Failure to Assess, Document, and Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse and neglect, as evidenced by the lack of assessment, documentation, investigation, and reporting of injuries of unknown origin for two cognitively impaired residents. One resident, with diagnoses including Paranoid Schizophrenia and Alzheimer's Disease, was found with multiple unexplained injuries over several days, including knots on the forehead, swelling and pain in the right hand, abrasions and bruising on the neck, and an open wound on the abdomen. Despite these findings, there was no timely documentation of falls, occurrence reports, or investigations into the causes of these injuries. Staff interviews revealed that the resident was frequently found on the floor, but this was considered part of his care plan, and no head-to-toe assessments or neuro-checks were performed after such incidents. Nurses and CNAs did not consistently notify each other or the physician about these events, and the DON was notified but did not initiate an investigation or report the injuries to state agencies. Another resident, also cognitively impaired, was documented with red scratches on the face, a knot and bruising on the head, and a swollen hand resulting in a finger fracture. Nursing staff failed to assess these injuries, document their origin, or notify the physician at the time of occurrence. No occurrence reports or investigations were completed for these injuries of unknown origin. The facility's own policy required staff to identify, document, and report all types of abuse and injuries of unknown origin, but this was not followed in these cases. Interviews with facility staff, including the Medical Director, LPNs, CNAs, and the DON, confirmed a lack of understanding and implementation of abuse and neglect reporting protocols. Staff admitted to not completing occurrence reports, not performing required assessments, and not notifying the physician or state agencies as required. The DON stated that she did not believe the injuries occurred at the facility and therefore did not initiate an investigation. The lack of documentation, assessment, and reporting placed all residents at risk and resulted in the facility being cited for Immediate Jeopardy at F-600.
Failure to Timely Report and Document Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were reported immediately, but not later than two hours after the allegation was made, for two of nine sampled residents reviewed for abuse. Facility policy required that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported promptly to appropriate authorities, including the State licensing agency, Ombudsman, resident representative, law enforcement, and the attending physician. The policy also required a written report of the findings of the investigation within five working days. However, for the residents in question, the facility did not complete occurrence reports, head-to-toe assessments, or document how the injuries occurred. There was also a lack of detailed descriptions of the injuries in the medical records. One resident, with diagnoses including Paranoid Schizophrenia, Alzheimer's Disease, and Hypertension, and who was moderately cognitively impaired, sustained multiple injuries of unknown origin on several occasions, including knots on the head, a painful swollen hand, a large bruise on the neck, and an open area on the abdomen. None of these incidents were properly documented or reported as required. The resident was later transferred to the emergency department, where life-threatening injuries were diagnosed, including a fractured sternum, multiple rib and lumbar vertebrae fractures, a cervical artery dissection, a lacerated spleen, and a subdural hematoma. The facility did not report these injuries to the State Agencies. Another resident, with severe cognitive impairment and total dependence on staff, sustained red scratches to the face, bruising to the head, and a swollen hand with a fractured finger. The facility again failed to complete an occurrence report, a head-to-toe assessment, or document how the injury occurred. The physician was not notified of the injuries, and there was no detailed description in the medical record. Interviews with the DON and Administrator confirmed that the injuries were not reported to the State Agencies and that documentation and reporting were insufficient.
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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 Memphis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allen Morgan Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Highlands Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 2 | 1 |
| Signature Healthcare Of Primacy | 3.7 mi | ★★★★★ | 7 | 0 |
| Quince Nursing And Rehabilitation Center | 3.7 mi | ★★★★★ | 19 | 0 |
| Waters Of Memphis A Rehabilitation & Nursing Ctr | 3.7 mi | ★★★★★ | 1 | 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.