A list of the most recent deficiencies for Shelby Pointe, Inc. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-12 | 2023-11-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-12 | 2023-11-30 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-10-12 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-11-30 | N |
| Keep all essential equipment working safely. | Health | 2023-10-12 | 2023-11-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-12 | 2023-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-12 | 2023-11-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-12 | 2023-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-12 | 2023-11-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-12 | 2023-11-30 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-11-21 | 2022-12-20 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-21 | 2022-12-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-21 | 2022-12-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-21 | 2022-12-20 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-11-21 | 2022-12-20 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-11-21 | 2022-12-20 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-11-21 | 2022-12-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-21 | 2022-12-20 | Y |
| 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 | 2021-08-05 | 2021-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-11-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-11-18 | Y |
| Report COVID19 data to residents and families. | Health | 2021-11-03 | 2021-11-18 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-05 | 2021-11-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-27 | 2021-06-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-27 | 2021-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-28 | 2019-04-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| 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. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-26 | 2019-04-15 | N |
