Shelby Oaks Post Acute

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to notify the provider and resident representative of a resident's change of condition and the failure to obtain stat labs and transfers for 1 of 4 (#76) sampled residents reviewed for notification of change.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services for residents with enteral feedings for 2 of 2 (Resident #6 and Resident #54) sampled residents reviewed for Percutaneous Endoscopic Gastrostomy (a plastic tube inserted through the abdominal wall into the stomach) (PEG) tube feedings.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to ensure the prevention and spread of infection were followed when 3 of 4 staff members (Certified Nurse Assistant (CNA) D and Licensed Practical Nurse (LPN) A, B and C) failed to wear proper personal protective equipment (PPE), failed to use a barrier during medication administration and failed to perform hand hygiene during incontinent care, wound care, medication administration and catheter (a thin flexible tube used to drain fluids from the body) care.

Inspectors wroteBased on facility policy review, medical record review, Emergency Medical Services (EMS) run report review, hospital record review, Medicolegal Death Investigator email, and interview, the facility failed to protect the residents' right to be free from abuse for 2 of 9 (Resident #1 and Resident #13) sampled residents reviewed for abuse. On 8/21/2025, the medical record of Resident #1, a vulnerable and cognitively impaired resident, revealed a skin assessment that documented a knot (raised area) to the left and right side of Resident's #1's forehead. On 8/28/2025, the medical record revealed Resident #1's right hand was swollen, warm to the touch, and painful. [...]

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure injuries of unknown origin were reported immediately, but not later than 2 hours, after the allegation was made for 2 of 9 (Resident #1 and Resident #13) sampled residents reviewed for abuse.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to accurately assess the nutritional status and to follow the facility's policy for monitoring weights for 1 of 3 sampled residents (Resident #24) reviewed for weight loss. The facility's failure to provide nutritional interventions resulted in Actual Harm when Resident #24 had a severe weight loss of 11.13 % in six months.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration rate of less than 5% (percent) when 1 of 5 nurses (Licensed Practical Nurse (LPN) #6) failed to properly administer medications for 1 of 5 sampled residents (Resident #31) observed during medication administration. This resulted in a medication administration error rate of 56 %.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure food was food was prepared and served under sanitary conditions when soiled serving scoops were used during serving, when 2 of 6 staff members (Cook #1, Dietary Aide #1) failed to perform appropriate hand hygiene during food preparation and serving, and when 4 of 12 staff members (Certified Nursing Assistant (CNA) #1, #2, Licensed Practical Nurse (LPN) #1, and Assistant Director of Nursing) failed to perform appropriate hand hygiene during dining.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when 5 of 12 staff members (Certified Nursing Assistant (CNA) #1 and #2, Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN) #3 and Business Office Coordinator) referred to residents as feeders, failed to knock prior to entering resident rooms, and stood over residents during dining observations.

Inspectors wroteBased on observation and interview, the facility failed to provide privacy for 7 of 7 residents (Resident #1, #12, #18, #27, #33, #41, and #57) during a group interview with Resident Council members.

Inspectors wroteBased on review of resident trust accounts, policy review, medical record review, and interview, the facility failed to refund the residents' funds within 30 days of death or discharge for 1 of 1 sampled resident (Resident #171) reviewed for trust funds.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to follow the comprehensive Care Plan for 2 of 21 sampled residents (Resident #24 and #57) reviewed for nutrition via Percutaneous Endoscopic Gastrostomy (PEG tube) and for falls.

Inspectors wroteBased on facility documentation review and interview the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for 16 of 20 days (10/8/2022, 10/9/2022, 10/15/2022, 10/16/2022, 10/22/2022, 10/23/2022, 10/29/22, 10/30/22, 11/4/22, 11/5/22, 11/6/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, and 11/11/22) reviewed.

Inspectors wroteBased on policy review, facility documentation review, observation, and interview, the facility failed to post the Daily Nurse Staffing form for 1 of 2 days of survey.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unattended and unsecured in 1 of 5 (300 Hall Medication Cart) medication storage areas, and in 1 resident room.

Inspectors wroteBased on observation and interviews policy review, the facility failed to ensure practices to prevent the potential spread of infection when 2 of 2 staff members (Activity Director and Certified Nursing Assistant (CNA) #4) failed to clean the reusable equipment before and after use.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure a continuous tube feeding was administered at the ordered rate, and failed to ensure the resident's head of bed was elevated 30 degrees while a continuous feeding was infusing for 1 of 6 sampled residents (Resident #52) reviewed for tube feedings.

Inspectors wroteBased on medical record review and interview, the facility failed to follow Physician's Orders for required laboratory monitoring for medications and failed to monitor blood sugar levels for 2 of 5 sampled residents (Resident #9 and #12) reviewed for unnecessary medication use.

Inspectors wroteBased on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 1 of 5 nurses (Licensed Practical Nurse (LPN) #1) failed provide a substantial snack or meal within 15 minutes of insulin administration for Resident #62. The failure to provide a substantial snack or meal within 15 minutes of insulin administration resulted in a significant medication error.

Inspectors wroteBased on observation and interview, the facility failed to properly store and maintain medications safely when 1 of 5 nurses (Licensed Practical Nurse (LPN) #3) left medications unattended and out of sight during medication pass observation.

Inspectors wroteBased on Environmental Cleaning Infection Control Compliance Log, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 5 nurses (Licensed Practical Nurse (LPN) #3 and 4) placed a clean glucometer in their pocket and placed medication cups on top of each other, contaminating the medications in each cup.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide a functioning call light for 1 of 24 sampled residents (Resident #170) which had the potential to result in unmet care needs.