Shelby Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike dining environment for seven anonymous resident council residents of eight reviewed for homelike environment.

Inspectors wroteThis citation pertains to Intake 2982336. Based on interview and record review, the facility failed to ensure a copy of the care plan and updates were provided to the resident or the resident representative for one resident (R120) of two reviewed for participation in care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents (R1 and R12) out of two reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure repositioning and dressing changes were completed timely for one resident (R120) of five reviewed for pressure ulcer care and skin management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure indwelling catheter and hand hygiene infection control practices were followed for one resident (R1) out of one reviewed for catheter care and hand hygiene during care.

Inspectors wroteThis citation pertains to intake 2568581. Based on observation, interview and record review, the facility failed to ensure resident care needs were met timely for six residents (R707, R700, R708, R709, R706, and R704) of twelve reviewed for resident care.

Inspectors wroteThis citation pertains to intake MI00153799. Based on observation, interview, and record review, the facility failed to maintain a sanitary environment in one of one kitchenettes located off the main dining room.

Inspectors wroteThis citation pertains to intake MI00151590 Based on interview and record review, the facility failed to promptly identify, assess, and contact physician for an acute change in condition for one resident (R902) out of two reviewed for change in condition, resulting in pain and hospitalization.

Inspectors wroteThis citation pertains to Intake MI00151476. Based on interview and record review, the facility failed to provide supervision during medication administration for one resident (R900) out of one reviewed for self administration of medications.

Inspectors wroteR106 On 03/20/2025 at 07:35 AM, Licensed Practical Nurse (LPN) B retrieved the glucometer tray from medication carts bottom drawer and entered R106's room that had a PPE [NAME] on the door with a sign specifying what PPE to don (gown, gloves, and mask) for the room. LPN B was observed to place glucometer tray and blood pressure cuff on R106's bed without a barrier, hand hygiene was not performed, PPE was not used. LPN B was not satisfied with the reading obtained for R106's blood pressure and left the room to obtain a wrist blood pressure machine. No hand hygiene performed. Upon completion of these tasks LPN B took the equipment and left R106's room. Hand hygiene was not performed. Blood pressure equipment was returned to nursing station, the glucometer tray replaced in medication cart without cleaning. No hand hygiene was performed upon leaving R106's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled for two residents (R51 and R78) of ten residents reviewed, three of thirteen medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for six residents (R1, R15, R41, R53, R78, and R110 ) of six residents reviewed for call light accessibility.

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order for an advance directive (form designed to communicate health care treatments in advance) upon admission for one resident (R106) out of two reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for one resident (R121) of two residents reviewed for PASARR screening.

Inspectors wroteBased on interview and record review, facility failed to ensure comprehensive care plans were developed and updated for two (R51 and R89) of six resident reviewed care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient feeding assistance for one resident (R142) out of one reviewed for Activities of Daily Living (ADL).

Inspectors wroteRelated to MI00150481 Based on interview and record review, the facility failed to ensure one resident (R131) of one reviewed for outside of facility consultations recieved the recommendations from an consultant appointment. Findings Include: Review of the medical record for R131 revealed an admission into the facility on 5/28/2023 with pertinent diagnoses of: Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety. R131 was evaluated by a consulting hearing service. The consulting physician was unable to remove impacted ear wax for R131 and recommended a medication to soften the wax with a return visit in 1-3 months. That order was not noted or carried out. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a hand splint as ordered for one resident (R89) of two residents reviewed for range of motion.

Inspectors wroteBased on interview and record review, the facility failed to complete an initial Abnormal Involuntary Movement Scale (AIMS) assessment for one resident (R146) out of one reviewed for antipsychotic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences for one resident (R142) out of one reviewed for food.

Inspectors wroteThis citation pertains to Intake MI00147833. Based on observation, interview, and record review, the facility failed to ensure a comprehensive nursing assessment was completed and timely acute care emergent hospital transfer for one Resident (R901) of three residents reviewed for care, when R901 sustained a fall with head trauma and bleeding while taking anticoagulant medication.

Inspectors wroteThis citation pertains to Intake: M100142677. Based on interview, and record review, the facility failed to notify the physician of unavailable medication for one resident (R700) out of one reviewed for medication administration.

Inspectors wroteThis citation pertains to Intake MI00142677. Based on observation, interview, and record review, the facility failed to provide feeding assistance for one resident (R701) out of two reviewed for nutrition. Findings Include: On 2/21/2024 at 9:13 AM, R701 was observed laying in bed. R701 was laying flat in bed with their breakfast tray off to the side of them sitting on their bedside table. R701 was observed trying to reach for their food. Upon observing their meal ticket, it documented that R701 was a 1:1 feed and should have built-up utensils. R701's utensils were observed to have the red built up part removed from the silverware. R701 was attempting to pick up their food with their hands. On 2/21/2024 at 9:15 AM, R701 stated that sometimes people help them eat and sometimes they do not. R701 stated that no one had been in to help them today and that they were hungry. [...]

Inspectors wroteThis citation pertains to Intakes M100136222, MI00137808, M100141129, and MI00141971. Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to provide a timely response to call lights and resident requests/needs, affecting three residents (R164, R230, and R283) of three reviewed for staffing, resulting in resident frustration and unmet care requests and needs.

Inspectors wroteThis citation pertains to Intake MI00137759. Based on observation, interview, and record review the facility failed to provide fresh drinking water for one resident (R164) of one reviewed for resident rights, resulting in feelings of frustration.

Inspectors wroteThis citation pertains to Intake MI00141403. Based on interview and record review, the facility failed to involve a resident (R333) in treatment decisions for one of one residents reviewed for plans of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy during a blood draw for one sample residents (R230) and maintain the call light within resident reach for two (R39 and R100) of seven residents reviewed. Findings Include: R230 On 1/21/24 at 12:39 PM, R230 was interviewed regarding the stay at the facility and reported some concerns. At that time Phlebotomist H entered the room and request to collect a blood sample from R230. R230's door was opened to the hallway and their roommate was in the room with the privacy curtain pulled halfway between the beds. R230's roommate was observed to be assisted to the restroom by a staff member, which required to pass by R230's bed. R230 lab draw was exposed to the roommate and to the people that passed by the hallway. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment for two (R100 and R116) of seven residents reviewed.

Inspectors wroteThis citation pertains to Intake MI00141321. Based on observation, interview, and record review the facility failed to update resident fall interventions on the care plan following resident falls for one (R110) of seven residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain lab results in a timely manner for one (R335) of one residents reviewed for laboratory services. Findings Include: Resident 335 A review of the medical record revealed that R335 admitted into the facility on 1/12/2024 with a diagnosis of Dementia. A review of the Minimum Data Set assessment revealed an impaired cognition. R335 also required moderate to partial assistance with bed mobility and transfers. R335 was also noted to be on multiple psychiatric medications. A review of a physician's order revealed a lab order for Valproic acid and Ammonia levels dated 1/16/2024. A request for the lab results was made and review of the results revealed that the lab was not collected until 1/22/2024 during survey. A review of the lab results revealed the following, Valproic Acid result 18.0. Reference Range 50-100. [...]

Inspectors wroteThis citation pertains to Intake MI00140703. Based on interview and record review, the facility failed to provide wound care treatments as ordered, reposition in a timely manner, and apply heel boots for two residents (R229 and 337) of seven reviewed for care and treatment. Findings Include: R229 A review of the Intake noted, It was alleged facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores. A review of R229's admission Assessment noted, Comments: DTI (deep tissue injury) to right buttocks. Weeping edema to BLE (Bilateral Lower Extremities). Blisters to groin. Bilat heels intact. Order: Triad Hydrophilic Wound Dress Paste (wound Dressing) Apply to Buttock/groin topically every shift for wound care. Start date 9/13/22. On 1/23/24 at 11:59 AM, Wound Care Nurse B was asked about the treatments for R229 wound. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely podiatry services for one resident (R138) of one reviewed for foot care, resulting in delayed treatment and long toenails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change an Peripherally Inserted Central Catheter (PICC) line dressing per physician orders for one residents (R152) of two residents. Findings Include: R152 On 1/21/24 at 9:52 AM, R152 was observed in their room lying in bed. In R152's room there was an IV (intravenous) pole with a completed medication bag hanging from the pole. On 1/22/24 at 10:29 AM, R152's right arm dressing was observed with a date of 1/14 (1/14/24). R152 was asked about the dressing change and could not remember if the facility changed it. The dressing was observed to be peeling off R152's arm. A review of R152's treatment administration record noted, on 1/22/24, blank and without documentation of the treatment completed as scheduled on 1/21/24. Further reviewed noted, Order: Change PICC line Dressing according to policy (R) (right) arm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to don and off personal protection equipment (PPE) for a resident (R334) on droplet and contact isolation out of ten reviewed for infection control. Findings Include: On 1/21/2024, R334 was observed in their room laying in bed. R334 door was open with a contact precaution sign on it. PPE was observed in a box hanging by the room. On 1/21/2024 at 9:59 AM, a certified nursing assistant (CNA) was observed entering the room without donning PPE. The CNA was observed picking up a breakfast tray out of the room. On 1/21/2024 at 10:04 AM, an interview was conducted with Licensed Practical Nurse (LPN) E regarding R73. LPN E stated that R73 was on contact and droplet precautions due to being exposed to Covid-19, however they had not had a positive test. [...]

Inspectors wroteThis citation pertains to Intake MI00135407. Based on interview and record review, the facility failed to ensure the assessed number of staff were used during shower care for one resident (R901) of three whose falls were reviewed resulting in a resident fall from a shower bed and sustained bruising, lacerations and bleeding to the face and head.

Inspectors wroteThis citation pertains to intake MI00139057. Based on interview and record review, the facility failed to schedule a follow-up urology appointment as indicated upon admission, adequately document assessments immediately prior to and after the initial insertion of an indwelling catheter (tube inserted into the bladder to drain urine), notify the resident's representative when the catheter was inserted, and failed to recognize the need for outside care, for one resident (R1) of three reviewed, resulting in ineffective coordination of care, resident discomfort, catheter-related complications, and hospitalization.