Deficiency Records for Shelby Skilled Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Shelby Skilled Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-09-22 | 2023-09-29 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-16 | 2022-07-11 | 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 | 2022-06-14 | 2022-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-14 | 2022-07-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-14 | 2022-07-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-14 | 2022-07-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-14 | 2022-07-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-14 | 2022-07-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-13 | 2019-08-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-13 | 2019-08-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-13 | 2019-08-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-13 | 2019-08-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-13 | 2019-08-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-13 | 2019-08-02 | 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 | 2019-06-13 | 2019-08-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-10 | 2019-08-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-10 | 2019-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-10 | 2019-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-10 | 2019-08-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-10 | 2019-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-10 | 2019-08-02 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2019-06-10 | 2019-08-02 | 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 | 2018-05-24 | 2018-07-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-24 | 2018-07-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-05-24 | 2018-07-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-24 | 2018-07-17 | 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 | 2018-05-24 | 2018-07-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-05-24 | 2018-07-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-05-24 | 2018-07-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-24 | 2018-07-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-24 | 2018-07-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-24 | 2018-07-17 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-05-24 | 2018-07-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-24 | 2018-07-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-24 | 2018-07-17 | 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 | 2018-05-24 | 2018-07-17 | N |
| 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. | Health | 2018-05-24 | 2018-07-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-05-24 | 2018-07-17 | 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 | 2018-05-24 | 2018-07-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-24 | 2018-07-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-24 | 2018-07-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-05-24 | 2018-07-17 | N |
| Develop a communication plan. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-21 | 2018-07-17 | N |
