A list of the most recent deficiencies for Shelbyville Rehab and Hlth C Ctr. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-23 | 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 | 2023-07-19 | 2023-08-22 | N |
| Post nurse staffing information every day. | Health | 2023-07-19 | 2023-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-19 | 2023-08-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-07-19 | 2023-08-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-07-19 | 2023-08-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-19 | 2023-08-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-19 | 2023-08-21 | 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 | 2023-07-19 | 2023-08-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-19 | 2023-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-19 | 2023-08-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-07-19 | 2023-08-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-07-24 | 2023-08-11 | 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 | 2023-07-24 | 2023-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-24 | 2023-08-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-24 | 2023-07-25 | 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 | 2023-05-03 | 2023-05-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-13 | 2023-03-31 | Y |
| 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 | 2023-03-13 | 2023-03-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-03-31 | Y |
| 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 | 2023-01-26 | 2023-02-17 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-07 | 2022-07-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-07 | 2022-07-25 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-24 | 2022-07-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-24 | 2022-07-22 | 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 | 2022-06-26 | 2022-07-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-06-07 | 2022-06-24 | 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 | 2022-06-07 | 2022-06-24 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-07 | 2022-06-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-07 | 2022-06-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-07 | 2022-06-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-07 | 2022-06-24 | 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 | 2022-06-07 | 2022-06-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-07 | 2022-06-24 | 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 and maintain the bed rail. | Health | 2022-06-07 | 2022-06-24 | 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 | 2022-06-07 | 2022-06-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-07 | 2022-06-24 | 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 | 2022-06-07 | 2022-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-07 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-30 | 2021-06-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-30 | 2021-05-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-30 | 2021-05-23 | 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 | 2021-04-16 | 2021-05-08 | 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 | 2021-04-16 | 2021-05-08 | 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 | 2021-04-16 | 2021-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-16 | 2021-05-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-16 | 2021-05-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-04-16 | 2021-05-08 | N |
