A list of the most recent deficiencies for Shelbyville Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-29 | 2023-07-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-28 | 2023-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-28 | 2023-07-15 | N |
| 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. | Health | 2023-06-28 | 2023-07-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-06-28 | 2023-07-15 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-28 | 2023-07-15 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-06-28 | 2023-07-15 | N |
| Keep all essential equipment working safely. | Health | 2023-06-28 | 2023-07-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-28 | 2023-07-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-29 | 2023-07-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-29 | 2023-07-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-03 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-20 | 2022-05-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-05-20 | 2022-05-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-20 | 2022-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-20 | 2022-05-26 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-05-20 | 2022-05-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-20 | 2022-05-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-20 | 2022-05-23 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-20 | 2022-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-19 | 2022-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-28 | 2022-01-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-15 | 2021-11-01 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-15 | 2021-11-01 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-10-15 | 2021-11-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-25 | 2021-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-25 | 2021-04-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-25 | 2021-04-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-25 | 2021-04-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-03-25 | 2021-04-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-25 | 2021-04-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-25 | 2021-04-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-25 | 2021-04-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-25 | 2021-04-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-25 | 2021-04-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-03-24 | 2021-03-30 | N |
