Shelby Oaks Post Acute

In the surveyor’s words

From the most serious findings on record at Shelby Oaks Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 30, 2025

  Based 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. […]

• Actual harm, isolatedF692Nov 17, 2022

  Based 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. The findings include: 1. Review of the facility's policy, Dietary: Weight Monitoring revised 11/9/2021, revealed .Weight can be a useful indicator of nutritional status. […]

• No harm, potential for more than minimal, patternF759Nov 17, 2022

  Based 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 %. The findings include: Review of the facility's policy titled Medication Administration, revised 10/24/2022, revealed .Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order .Check to ensure the medication is given within the time constraints of the order .Double check directions and… […]

• No harm, potential for more than minimal, patternF812Nov 17, 2022

  Based 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. The findings include: 1. Review of the facility's policy titled Dietary - Mechanical Dish Washing, with a revision date of 10/15/2022, revealed .To ensure dishes and utensils are cleaned under sanitary conditions. […]

• No harm, potential for more than minimal, isolatedF580Jan 8, 2026

  Based 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. The findings include: 1. Review of the facility policy titled, Change in a Resident's Condition or Status, dated February 2021, revealed .Our facility notifies the resident, his or her attending physician and the resident representative of change in the resident's medical/mental condition .a nurse will notify the resident's representative.when.it is necessary to transfer the resident to a hospital/treatment center. 2. […]