Inspection Reports for
Shelby Oaks Post Acute
5070 Sanderlin Ave, Memphis, TN 38117, United States, TN, 38117
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse and neglect involving injuries of unknown origin to residents at Shelby Oaks Post Acute.
Complaint Details
The complaint investigation found that Resident #1 and Resident #13 sustained injuries of unknown origin that were not properly assessed, documented, or reported. Resident #1 suffered multiple severe injuries leading to death. The facility failed to complete occurrence reports, notify physicians timely, and report to state agencies. Immediate Jeopardy was identified related to failure to protect residents from abuse and neglect.
Findings
The facility failed to protect residents from abuse and neglect, specifically failing to identify, assess, investigate, and report injuries of unknown origin for two residents. Immediate Jeopardy was identified and later removed, but ongoing noncompliance was noted related to monitoring corrective actions.
Deficiencies (2)
F 0600: The facility failed to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect. Injuries of unknown origin were not properly assessed, documented, or investigated for two residents, resulting in serious harm and death for one resident.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and failed to report investigation results to proper authorities for two residents with injuries of unknown origin.
Report Facts
Residents reviewed for abuse: 9
Residents affected: 2
Date survey completed: Sep 30, 2025
Date Immediate Jeopardy began: Aug 21, 2025
Date Immediate Jeopardy removed: Sep 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unnamed Director of Nursing | Director of Nursing | Named in relation to failure to investigate and report injuries of unknown origin |
| Unnamed Administrator | Administrator | Named in relation to failure to report injuries and manage abuse investigation |
| Unnamed Medical Director | Medical Director | Interviewed regarding notification and reporting of injuries |
| LPN A | Licensed Practical Nurse | Interviewed about failure to complete occurrence reports and assessments |
| LPN B | Licensed Practical Nurse | Interviewed about resident behavior and fall documentation |
| Nurse Practitioner | Nurse Practitioner | Interviewed about notification and assessment of injuries |
| MDS Coordinator | MDS Coordinator | Interviewed about fall documentation and injury reporting |
| CNA N | Certified Nursing Assistant | Interviewed about observations of resident injuries |
| Wound Nurse | Wound Nurse | Interviewed about wound assessment and documentation |
| CNA L | Certified Nursing Assistant | Interviewed about resident behavior and fall reporting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 11, 2025
Visit Reason
The Health Facilities Commission conducted a complaint survey at Shelby Oaks Post Acute to investigate alleged violations of licensure statutes and regulations.
Complaint Details
The visit was complaint-related, conducted pursuant to Tenn. Code Ann. § 68-11-210. The investigation was completed on October 14, 2025. Specific substantiation status is not stated.
Findings
The survey revealed violations of licensure statutes and regulations that directly impact the care of patients in the nursing home, resulting in the assessment of a Type B Civil Monetary Penalty.
Report Facts
Civil Monetary Penalty amount: 500
Civil Monetary Penalty count: 1
Penalty payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Logan Grant | Executive Director | Signed the order assessing the civil penalty. |
| Caroline R. Tippens | Director of Licensure & Regulation | Copied on the order. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Nov 17, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, privacy during resident council meetings, timely refund of resident trust funds, comprehensive care planning, nutritional monitoring and interventions, RN staffing coverage, nurse staffing posting, medication administration errors, medication storage and security, food preparation and hygiene practices, and infection prevention and control practices.
Deficiencies (11)
F 0550: The facility failed to maintain residents' dignity and respect when staff referred to residents as feeders, failed to knock before entering rooms, and stood over residents during meal assistance.
F 0565: The facility failed to provide privacy for 7 residents during a Resident Council meeting held in an open dining room accessible to staff and others.
F 0569: The facility failed to refund resident trust funds within 30 days of death or discharge for 1 resident, issuing the refund 55 days late.
F 0656: The facility failed to follow the comprehensive care plan for 2 residents, including lack of use of an abdominal binder and failure to document hourly staff rounds for fall risk.
F 0692: The facility failed to accurately assess and intervene for severe weight loss in 1 resident, resulting in actual harm with an 11.13% weight loss over 6 months and failure to ensure enteral feeding was administered as ordered.
F 0727: The facility failed to ensure a Registered Nurse was on duty for 8 consecutive hours daily for 16 of 20 days reviewed.
F 0732: The facility failed to post daily nurse staffing information for 1 of 2 days observed during the survey.
F 0759: The facility failed to ensure medication error rates were below 5% when 1 nurse improperly administered medications to 1 resident, crushing and mixing medications and administering late doses, resulting in a 56% medication error rate.
F 0761: The facility failed to ensure medications were properly stored and secured when medications were found unattended and unsecured on a medication cart and in a resident room.
F 0812: The facility failed to ensure food was prepared and served under sanitary conditions, including use of soiled serving scoops, failure of staff to perform hand hygiene during food preparation and dining assistance.
F 0880: The facility failed to implement infection prevention and control practices when reusable equipment was not cleaned before and after use by staff.
Report Facts
Medication error rate: 56
Days without 8 consecutive hours RN coverage: 16
Weight loss percentage: 11.13
Days late refund issued: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication administration error involving crushing and mixing medications |
| Interim Director of Nursing | Interim Director of Nursing | Confirmed deficiencies related to care plans, medication administration, and hand hygiene |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in resident dignity deficiency and hand hygiene during dining |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Named in resident dignity deficiency and hand hygiene during dining |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Named in resident dignity deficiency and hand hygiene during dining |
| Activity Director | Activity Director | Named in infection prevention deficiency for failure to clean reusable equipment |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in resident dignity deficiency and hand hygiene during dining |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in resident dignity deficiency |
| Business Office Coordinator | Business Office Coordinator | Named in resident dignity deficiency and trust fund refund delay |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding food preparation and hygiene practices |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 8, 2021
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with healthcare regulations and ensure resident safety and care quality at Shelby Oaks Post Acute.
Findings
The facility was found deficient in multiple areas including improper feeding tube care, failure to follow physician's orders for medication monitoring, significant medication errors, unsafe medication storage, infection control lapses, and a non-functioning call light system.
Deficiencies (6)
F 0693: The facility failed to ensure a continuous tube feeding was administered at the ordered rate and the resident's head of bed was elevated 30 degrees during feeding for Resident #52.
F 0757: The facility failed to follow physician's orders for required laboratory monitoring for medications and failed to monitor blood sugar levels for Residents #9 and #12.
F 0760: The facility failed to ensure residents were free from significant medication errors when a nurse failed to provide a substantial snack or meal within 15 minutes of insulin administration for Resident #62.
F 0761: The facility failed to properly store and maintain medications safely when a nurse left medications unattended and out of sight during medication pass observation.
F 0880: The facility failed to ensure infection prevention practices were maintained when nurses placed a clean glucometer in their pocket and stacked medication cups, contaminating medications.
F 0919: The facility failed to provide a functioning call light for Resident #170, which had the potential to result in unmet care needs.
Report Facts
Medication administration time delay: 48
Medication infusion rate: 55
Water flush infusion rate: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed incorrect feeding tube rate and head of bed position; administered insulin late relative to meal |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Left medications unattended and placed glucometer in pocket |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Stacked medication cups contaminating medications |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration timing, medication storage, infection control, and call light issues |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed physician ordered laboratory tests had not been obtained for Residents #9 and #12 |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 26, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Shelby Oaks Post Acute facility.
Findings
The facility was found deficient in ensuring nutritional interventions were followed for one resident and failed to implement proper infection prevention and control practices, including hand hygiene and handling of soiled linens.
Deficiencies (2)
F 0692: The facility failed to ensure nutritional interventions were followed for Resident #57, who did not receive recommended supplements PRO Heal and Multivitamin with Minerals as ordered by the registered dietician.
F 0880: The facility failed to ensure infection prevention practices were followed when one nurse did not perform hand hygiene between glove changes and two staff members improperly handled soiled linens by placing them on the floor.
Report Facts
Residents sampled for nutrition: 3
Residents affected by nutrition deficiency: 1
Residents affected by infection control deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed nutritional supplements should have been administered and hand hygiene and linen handling practices | |
| Licensed Practical Nurse (LPN) #1 | Failed to perform hand hygiene between glove changes and improperly handled soiled linens | |
| Certified Nursing Assistant (CNA) #4 | Improperly handled soiled linens during perineal care |
Viewing
Loading inspection reports...
