Shelby Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Shelby Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 2, 2025

  This 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 . Findings include: A review of intake MI00151590 noted the following, This facility failed to provide [R902] with a timely evaluation of a head injury that likely was the cause of [R902's] mental status change and instead appeared to choose to attempt to sedate them. A review of the medical record revealed that R902 admitted into the facility on [DATE] with the following medical diagnoses, Acute Posthemorrhagic Anemia and Gastrointestinal Hemorrhage. […]

• Actual harm, isolatedF684Nov 13, 2024

  This 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. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to assess a change of condition following the fall for R901. A review of R901's medical record revealed, R901 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that include Quadriplegia and Atrial fibrillation (AFIB). […]

• Actual harm, isolatedF689Sep 27, 2023

  This 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. Findings include: A review of a complaint for R901 revealed: On 9/14/23, (R901) had one person assisting (them) in a shower and (R901) was dropped during the shower. (R901) sustained multiple fractures to the nose, jaw and skull. Additional injuries included five fractures to the right eye socket, 18-20 stitches on the forehead and a brain bleed. (R901) is currently at the hospital. […]

• Actual harm, isolatedF690Sep 18, 2023

  This 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 . […]

• Actual harm, isolatedF686Oct 13, 2022

  Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers and implement pressure ulcer interventions for two (R42 and R111) of three residents reviewed, resulting in facility acquired pressure ulcers, the potential for the worsening of existing pressure ulcers, and/or the development of additional skin impairments. Findings include: R111 On 10/13/22 at 11:04 AM, R111 was observed lying in bed on their back with wound dressings observed on both their left and right elbow. R111 was asked about their wound dressings and explained that they are pressure ulcers that were acquired while staying at the facility. […]