Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shelby Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was lowered to the floor by an STNA after missing a recliner, during which the resident's head brushed a bedside table. The incident was reported to two LPNs, but neurological checks were not initiated until several hours later, despite facility policy requiring prompt assessment after falls with possible head injury.
A resident experienced a significant weight loss of 21.07% since admission, but the facility failed to notify the physician as required by policy. Despite multiple documented weight changes, the physician was not informed, and the dietician was unaware of the notification status. The facility's policy mandates reporting significant weight changes to the physician, which was not adhered to in this case.
A resident with multiple diagnoses and impaired cognition was readmitted to the facility with a left buttock shearing wound. Despite having a care plan for skin integrity, treatment orders were not implemented until four days after readmission, as confirmed by the DON.
A resident experienced a significant weight loss of 21.07% since admission, with no timely interventions or physician notification. Despite the resident's poor appetite and nausea attributed to medication, the dietician had only seen the resident once, and no nutritional supplements were ordered until after the deficiency was identified. The facility's policy on unplanned weight loss was not followed, leading to a failure in addressing the resident's nutritional needs.
A resident with a history of multiple health conditions was administered metoprolol tartrate despite physician orders to withhold it if the heart rate was below 65 bpm. The medication was given on three occasions when the resident's heart rate was below this threshold, contrary to the facility's medication administration policy.
A resident with a bacterial infection, ESBL, was readmitted to the facility, but contact isolation precautions were not implemented until two days later. The DON confirmed that precautions should have been in place upon readmission, as per the facility's policy on transmission-based precautions.
The facility did not complete required annual performance reviews for three STNAs, potentially impacting all residents. Personnel files for these aides, hired on various dates, lacked reviews for the past 12 months. The administrator confirmed the oversight, affecting the facility's 46 residents.
Two residents were affected by significant medication errors when a nurse administered the wrong medication to one resident and an extra dose to another. Both residents were monitored, and no adverse reactions were reported. The facility's DON confirmed the errors and provided education to staff on proper medication administration procedures.
A resident with multiple medical diagnoses was inadvertently administered a dose of Lyrica due to a nurse's error. The resident reported feeling loopy but had no adverse reactions. The incident was not documented in the resident's medical record, contrary to the facility's policy.
An LPN failed to follow infection control procedures by picking up dropped medications with bare hands and administering them to a resident with severe cognitive impairment and multiple medical conditions. This action violated the facility's policy on administering medications.
A resident requiring partial assistance for ADLs did not receive scheduled showers on multiple occasions. The DON instructed an STNA to retroactively document a shower refusal inaccurately. The facility's policy mandates accurate documentation and reporting of care refusals.
The facility failed to ensure accurate documentation of a resident's showers, affecting one resident who did not receive scheduled showers on multiple occasions. The DON instructed an STNA to retroactively mark a shower as 'refused,' despite knowing it was not accurate. This deficiency was investigated under Complaint Number OH00152522.
Failure to Timely Initiate Neurological Checks After Resident Fall with Head Injury
Penalty
Summary
The facility failed to ensure that a neurological evaluation was promptly initiated after a resident experienced a fall with a reported head injury. The resident involved had severe cognitive impairment and required significant staff assistance for daily activities. On the day of the incident, a State Tested Nursing Assistant (STNA) lowered the resident to the floor after the resident attempted to sit and missed the recliner, during which the resident's head brushed against a bedside table. The STNA reported the incident to two Licensed Practical Nurses (LPNs), indicating that the resident may have brushed her head on the table. Despite this information, neither LPN initiated neurological checks immediately following the fall. Documentation shows that neurological checks were not started until several hours after the incident, following clarification with the facility's Nurse Practitioner. The facility's fall investigation confirmed that there was no documentation of neuro checks being initiated until later in the day, despite the facility's policy requiring neurological assessments after unwitnessed falls or suspected head injuries. Interviews with staff confirmed that the required neurological checks were not performed in a timely manner after the fall.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a physician of a resident's significant weight loss, which was a deficiency identified during the survey. The resident, who had a history of nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, Hodgkin lymphoma, and stroke, experienced a 21.07% weight loss since admission. Despite multiple documented instances of weight loss, there was no indication that the physician was informed. The resident's weight was recorded at various points, showing a decrease from 225.0 pounds to 177.6 pounds over a period of time. Interviews with the Dietician Consultant and the facility's Administrator and DON revealed that the dietician had not seen the resident due to the resident's hospitalizations and was unaware if the physician had been notified of the weight loss. The facility's policy required staff to report significant weight changes to the physician, but this was not done. The DON acknowledged that the physician was not notified of the weight losses, even though the physician assessed the resident and did not document a concern for weight loss.
Delayed Wound Treatment Implementation
Penalty
Summary
The facility failed to timely implement treatment for a wound on a resident, affecting one of the twelve residents reviewed for treatments. The resident, who was admitted with multiple diagnoses including nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin's Lymphoma, and stroke, was assessed with moderately impaired cognition and required maximum assistance for various activities. Upon readmission to the facility, the resident was noted to have a left buttock shearing wound. Despite the presence of a care plan focusing on impaired skin integrity, the facility did not put treatment orders in place for the resident's skin condition upon readmission on August 23, 2024, until August 27, 2024. The physician's orders for treating the wound, which included cleansing and applying A&D ointment every shift, were not implemented until four days after the resident's readmission. This delay in treatment was confirmed during an interview with the Director of Nursing.
Failure to Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to provide timely interventions to address significant weight loss in a resident, identified as Resident #13, who was admitted with multiple medical conditions including nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin lymphoma, and stroke. The resident experienced a 21.07% weight loss since admission, with weights documented on several occasions showing a downward trend. Despite this significant weight loss, there was no indication that the physician was notified, and no additional nutritional interventions were ordered. The resident's medical record and interviews revealed that the resident had a poor appetite, attributed to nausea as a side effect of medication, and had been hospitalized twice during her short admission. The Director of Nursing (DON) acknowledged the resident's poor appetite and stated that the physician was informed, and anti-nausea medication and laboratory work were ordered. However, the dietician had only seen the resident once since admission and had not ordered any nutritional supplements until after the deficiency was identified. The dietician consultant confirmed that the resident was on her radar and discussed weekly with the DON, but no supplements were started, and the physician was not informed of the weight loss. The facility's policy on unplanned weight loss indicated that staff and physicians should identify and authorize appropriate interventions, which was not followed in this case.
Failure to Withhold Medication as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of a blood pressure medication, metoprolol tartrate, for a resident. The resident, who was cognitively intact and had a medical history including skin cancer, enlarged lymph nodes, cerebral infarction, muscle weakness, and type two diabetes mellitus, was prescribed metoprolol tartrate 50 mg to be administered via G-tube three times a day for hypertension. The physician's order specified that the medication should be withheld if the resident's heart rate was less than 65 beats per minute. Despite these instructions, the medication was administered on three occasions when the resident's heart rate was below the specified threshold: once with a heart rate of 60 beats per minute, and twice with heart rates of 56 and 55 beats per minute, respectively. The Director of Nursing confirmed these instances of non-compliance with the physician's order. The facility's policy on administering medications, which mandates adherence to prescriber orders, was not followed in these instances.
Failure to Implement Timely Infection Control Precautions
Penalty
Summary
The facility failed to timely implement infection control precautions for a resident diagnosed with a bacterial infection, Extended-Spectrum Beta-Lactamase (ESBL). The resident, who had a history of nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin's lymphoma, and stroke, was readmitted to the facility with this diagnosis. Despite the resident's condition requiring contact isolation, the necessary precautions were not ordered until two days after the readmission. The Director of Nursing confirmed that the resident returned to the facility with the ESBL diagnosis and acknowledged that contact precautions should have been implemented immediately upon readmission. The facility's policy on isolation and transmission-based precautions, which dates back to 2001, mandates contact precautions for residents with infections that can be transmitted through direct or indirect contact. This lapse in timely implementation of infection control measures was identified during the review of the resident's medical records, staff interviews, and policy review.
Failure to Conduct Timely Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct performance reviews for nurse aides at least every 12 months, as required by regulations. This deficiency was identified through a review of personnel files and staff interviews. Specifically, the personnel files of three state tested nurse aides (STNAs) were found to be lacking performance reviews for the previous 12 months. STNA #115, hired on 03/05/01, STNA #118, hired on 04/03/23, and STNA #133, hired on 05/16/22, all had missing performance reviews. The facility's administrator confirmed that these reviews had not been completed as required, potentially affecting all residents in the facility, which had a census of 46 at the time of the survey.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that residents' medications were administered as ordered, resulting in significant medication errors for two residents. Resident #13, who had multiple medical diagnoses including osteoarthritis, gout, and end-stage renal disease, was inadvertently administered a dose of Lyrica. The error occurred when the nurse was interrupted during medication preparation and mistakenly gave the wrong medication to Resident #13. Although the resident felt loopy and experienced numb lips and mood swings, no adverse reactions were reported, and the resident remained alert and oriented. The incident was not documented in the medical record, but the resident and physician were notified of the error. Resident #12, with medical diagnoses including cellulitis, multiple sclerosis, and bipolar disorder, was given an extra dose of Lyrica during a morning medication pass. The nurse's progress note indicated that the resident was alert and oriented and that the physician was notified. The resident was monitored for any adverse reactions, but none were reported. The facility's policy on administering medications states that medications should be given according to prescriber's orders and that any errors should be documented, reported, and reviewed by the Quality Assurance Improvement Performance (QAPI) committee. The Director of Nursing (DON) confirmed both medication errors and stated that neither resident experienced a change in condition due to the errors. The facility conducted an investigation and provided education to the involved staff on medication administration policies, including the Five Rights of Medication Administration and verification of resident identity using photo identification on the Medication Administration Record (MAR). The facility also conducted audits and observations to ensure compliance with medication administration procedures.
Failure to Document Medication Error
Penalty
Summary
The facility failed to ensure a resident's medical record contained documentation involving a medication error. Resident #13, who has medical diagnoses including osteoarthritis, gout, hyperparathyroidism, diabetes mellitus, obesity, end stage renal disease, and atrial fibrillation, was inadvertently administered a dose of Lyrica in error. The incident occurred when the nurse, who was preparing another resident's medications, was interrupted and mistakenly administered the wrong medication to Resident #13. The resident reported feeling loopy but did not experience any pain or dizziness and remained alert and oriented. The facility staff monitored the resident for adverse reactions on the day of the error and the following days, with no adverse reactions reported. However, there was no documentation of the medication error in the resident's medical record. The Director of Nursing confirmed that the medical record for Resident #13 did not contain documentation related to the medication administration error. The facility's policy on administering medications, revised in April 2019, states that medication errors should be documented, reported, and reviewed by the Quality Assurance Performance Improvement committee. This deficiency represents non-compliance investigated under Complaint Number OH00153184 and ongoing non-compliance from a previous survey dated 04/14/24.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to follow infection control procedures during medication administration for Resident #14. The resident, who has severe cognitive impairment and requires significant assistance with daily activities, was observed receiving medications in a manner that violated the facility's infection control policy. Specifically, an LPN dropped two tablets onto the medication cart, picked them up with her bare hands, and placed them into a medication cup along with other medications before administering them to the resident. This action was confirmed by the LPN during an interview immediately following the observation. Resident #14 has medical diagnoses including hypertension, chronic obstructive pulmonary disease, and encephalopathy, and is on multiple medications as per physician orders. The facility's policy on administering medications, revised in April 2019, mandates that staff follow established infection control procedures, such as handwashing and antiseptic techniques. The LPN's failure to adhere to these procedures during medication administration was identified during a complaint investigation, highlighting a deficiency in the facility's infection control practices.
Failure to Provide Scheduled Showers and Inaccurate Documentation
Penalty
Summary
The facility failed to ensure a resident was provided with showers, affecting one resident out of four reviewed for showering. Resident #21, who was admitted with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, obesity, diabetes mellitus, and depression, was found to require partial assistance for activities of daily living (ADL) such as bathing. Despite being cognitively intact, the resident did not receive a shower on multiple occasions, including 04/01/24, as confirmed by both the resident and the State tested Nursing Assistant (STNA) #292. The STNA marked 'No' in the computerized charting instead of 'refusal' because the resident did not refuse the shower. The resident expressed dissatisfaction with missing showers due to his inability to perform all his own care due to his condition and weight. Further investigation revealed that the Director of Nursing (DON) instructed STNA #292 to fill out a shower sheet retroactively with a date of 04/01/24 and mark it as 'Refused,' despite knowing that the resident did not refuse the shower. The DON admitted to this action, stating she wanted to provide the surveyor with something, even though it was inaccurate. The facility's policy requires that shower sheets be signed by the nurse on duty and that any refusal of care be reported and documented accurately. The deficiency was investigated under Complaint Number OH00152522.
Inaccurate Documentation of Resident Showers
Penalty
Summary
The facility failed to ensure accurate documentation regarding a resident's showers, affecting one resident out of four reviewed for medical record accuracy. Resident #21, who was admitted with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, obesity, diabetes mellitus, and depression, was found to have discrepancies in his shower records. The resident's care plan indicated a risk for decline in ADL function, and the MDS revealed he required partial assistance for various personal hygiene tasks. Despite being cognitively intact, as indicated by a BIMS score of 15, Resident #21 reported not receiving his scheduled showers on multiple occasions, including on 04/01/24. This was corroborated by an STNA who confirmed the resident did not receive a shower on that date and that she had incorrectly marked 'No' in the computerized charting instead of 'refusal' because the resident did not refuse the shower. Further investigation revealed that the DON had instructed the STNA to fill out a shower sheet retroactively for 04/01/24, marking it as 'refused,' despite knowing that the resident had not refused the shower. The DON admitted to this action, stating she wanted to provide the surveyor with documentation, even though it was inaccurate. The facility's shower schedule and policy required that refusals be reported to the nurse on duty and documented in the computer charting system. The review of the Follow-Up Question Report for Resident #21 showed that the task of bathing was marked as not completed on 03/28/24 and 04/01/24. This deficiency was investigated under Complaint Number OH00152522.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sidney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Momentous Health At Sidney | 1.4 mi | — | 6 | 0 |
| Fair Haven Shelby County | 2.5 mi | — | 1 | 0 |
| Ohio Living Dorothy Love | 4 mi | — | 0 | 0 |
| Ayden Healthcare Of Piqua | 9.8 mi | — | 0 | 0 |
| Piqua Manor | 11.5 mi | — | 1 | 0 |
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