Cycle 1
Health 2022-11-17 · Fire 2022-11-17
13 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Memphis, TN
Shelby Oaks Post Acute
1-star overall rating with 1-star inspections with abuse icon flag with $126,318 in total fines with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
5070 Sanderlin Avenue, Memphis, TN
(901) 682-5677
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Links Healthcare Group
Operator or chain grouping
Approved since
2001-07-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
31 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,473
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.76% · Performance 21.88% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.22
Baseline 6.42% · Performance 6.87% · Measure score 3.22 · Achievement 3.22 · Improvement 0
Total nurse turnover
0.18
Baseline 78.31% · Performance 74.68% · Measure score 0.18 · Achievement 0 · Improvement 0.18
Adjusted total nurse staffing
1.42
Baseline 3.02 hours · Performance 3.48 hours · Measure score 1.42 · Achievement 1.42 · Improvement 1.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.74% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 18.57% · Lower 95% interval 7.83% |
| Discharge to community | 39.06% |
50.57%
11.5 pts worse
|
Worse than the National Rate · Eligible stays 62 · Observed rate 29.03% · Lower 95% interval 27.41% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 69.23% |
53.69%
15.5 pts better
|
Numerator 18 · Denominator 26 |
| Discharge mobility score | 65.38% |
50.94%
14.4 pts better
|
Numerator 17 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 4.21% |
8.2%
4 pts worse
|
Numerator 4 · Denominator 95 |
| Staff flu vaccination coverage | 25.25% |
42%
16.8 pts worse
|
Numerator 25 · Denominator 99 |
| Discharge function score | 73.08% |
56.45%
16.6 pts better
|
Numerator 19 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.9%
9.1 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.5%
2.3 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
3.6%
3.4 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.1% · Q3 8.9% · Q4 6.5% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.5% |
11.8%
14.7 pts worse
|
11.4%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 26.2% · Q3 41.5% · Q4 38.9% · 4Q avg 26.5% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.2%
2.9 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 5.8% · Q3 0.0% · Q4 5.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
32.2%
6.8 pts better
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 25.0% · Q3 19.5% · Q4 14.3% · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
18.1%
1.6 pts worse
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 25.0% · Q3 21.9% · Q4 12.9% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.7% |
19.9%
6.2 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
15.3%
0.7 pts better
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 18.2% · Q3 14.3% · Q4 10.5% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
1.9%
2.1 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 9.1% · Q3 2.2% · Q4 0.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.5% |
20.2%
11.7 pts better
|
19.8%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 14.8% · Q3 7.0% · Q4 4.8% · 4Q avg 8.5% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
5.4%
6 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 8.4% · Q3 14.5% · Q4 17.4% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
79.6%
15.5 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.9% · Q2 96.9% · Q3 100.0% · Q4 99.1% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
11.2%
0.9 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 11.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.6%
1.7 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.8% · Q3 5.6% · Q4 2.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.3% |
79.8%
12.5 pts better
|
79.7%
12.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 41.3% |
22.2%
19.1 pts worse
|
23.9%
17.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 41.3% · Observed 49.1% · Expected 28.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-08 · Fire 2021-07-08
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-09-26 · Fire 2019-09-26
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-11-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-05
D · Potential for more than minimal harm
2022-11-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-14
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-22
G · Actual harm
2022-11-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-22
E · Potential for more than minimal harm
2022-11-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-22
E · Potential for more than minimal harm
2022-11-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-10
D · Potential for more than minimal harm
2022-11-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-10
D · Potential for more than minimal harm
2022-11-17
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-11-17
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-11-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-11-17
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-11-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-10
D · Potential for more than minimal harm
2022-11-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-10
D · Potential for more than minimal harm
2022-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-22
D · Potential for more than minimal harm
2021-07-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-07-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-07-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-07-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-07-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-07-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-07-30
E · Potential for more than minimal harm
2019-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-10-04
Penalties and ownership
What sits behind the stars
$122,085
2025-09-30
Fine
Fine · fine $122,085
Fine
$4,233
2023-07-17
Fine
Fine · fine $4,233
Fine
Ownership
Links Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Rodriguez, Curtis
5% Or Greater Indirect Ownership Interest · Individual
Tilford, Toby
5% Or Greater Indirect Ownership Interest · Individual
5070 Sanderlin Avenue Tn LLC
5% Or Greater Mortgage Interest · Organization
Hines, Elbert
Operational/Managerial Control · Individual
Holt, Weston
Operational/Managerial Control · Individual
Links Healthcare Group LLC
Operational/Managerial Control · Organization
Rodriguez, Curtis
Operational/Managerial Control · Individual
Tilford, Toby
Operational/Managerial Control · Individual
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#3
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