Deficiency Records for Shelbyville Manor
Updated as of May 01, 2020
This is not the most recent data for Shelbyville Manor. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-06 | 2019-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-06 | 2019-07-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-06 | 2019-07-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-06 | 2019-07-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-06 | 2019-07-30 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-06 | 2019-07-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-06-06 | 2019-07-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-06 | 2019-07-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-06 | 2019-07-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-06 | 2019-07-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-06 | 2019-07-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-06-06 | 2019-07-30 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-06 | 2019-07-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install | Health | 2019-06-06 | 2019-07-30 | N |
| 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. | Health | 2019-06-06 | 2019-07-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-07-30 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-06-06 | 2019-07-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-24 | 2019-07-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-24 | 2019-06-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-24 | 2019-06-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-18 | 2018-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-18 | 2018-07-23 | N |
| Provide or obtain dental services for each resident. | Health | 2018-07-20 | 2018-07-23 | 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 | 2018-07-20 | 2018-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-18 | 2018-07-20 | 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 | 2018-07-20 | 2018-07-20 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2018-07-18 | 2018-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-18 | 2018-07-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-07-10 | 2018-07-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-10 | 2018-07-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-21 | 2018-01-16 | Y |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2017-06-19 | 2017-06-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-06-19 | 2017-06-22 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2017-06-19 | 2017-06-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-06-19 | 2017-06-20 | 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 | 2017-06-19 | 2017-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-19 | 2017-06-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-06-19 | 2017-06-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-19 | 2017-06-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-06-19 | 2017-06-20 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-04-14 | 2017-04-15 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-14 | 2017-04-15 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-14 | 2017-04-15 | Y |
