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 |