Shelby Oaks Post Acute
SHELBY OAKS POST ACUTE in MEMPHIS, TN — inspection on September 30, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 9/22/2025 at 3:45 PM, CNA L was asked about Resident #1‘s behavior the day before he went to the hospital. CNA L stated, .he was up in his Geri chair for a few hours, but we laid him down because he was tired and sleepy. CNA L was asked if he had fallen that day. CNA L stated, Yes, he rolled off the bed between the bed and the air conditioner, the mat would slide away from the bed, he would get on the side of the wall, but he was asleep, so we just put him back in bed. CNA L was asked if she told the nurse. CNA L stated, No, he was care planned for being in the floor. CNA L was asked if Resident#1 acted like he was hurt. CNA L stated, No he was asleep face down when we put him back in bed. CNA L was asked why the nurse wasn't notified. CNA L stated, .they usually just tell us to put him back in the bed.
During an interview on 9/23/2025 at 1:55 PM, the DON was asked when Resident #1 was throwing himself in the floor, where was the documentation of an occurrence report or head head-to-toe assessment, documentation the MD was notified, follow up documentation for his behaviors, and the interventions put into place were all documented in the medical record.
The DON stated I don't see any documentation of that in his [Resident #1] medical record.
The DON was asked if the facility provided adequate monitoring, supervision, adequate assessment and adequate interventions to keep Resident #1 safe in the facility.
The DON stated Yes.those type injuries he sustained couldn't have happ
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Shelby Oaks Post Acute
5070 Sanderlin Avenue Memphis, TN 38117
SUMMARY STATEMENT OF DEFICIENCIES
Administrator stated, The injuries could not have happened here at the facility.
The Administrator was asked how he knew the injuries did not occur at the facility.
The Administrator stated, .through our witness statements .
The Administrator was asked since this was your resident, and the facility was considered an advocate for (Named Resident #1) why wouldn't you report the injuries.
The Administrator stated, We decided to report the incident later, but there are no witnesses it occurred here.
The Administrator was asked how [Named Resident #1] sustained such serious life threatening injuries.
The Administrator stated, I do not know
Facility ID: