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Deficiency Records for Shipley Living
A list of the most recent deficiencies for Shipley Living. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Shipley Living. 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? |
|---|---|---|---|---|
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-08-14 | 2024-09-17 | 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 | 2024-08-14 | 2024-09-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-14 | 2024-09-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-14 | 2024-09-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-02 | 2024-08-09 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-07-02 | 2024-08-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-02 | 2024-08-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-02 | 2024-08-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-07-02 | 2024-08-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-02 | 2024-08-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-07-02 | 2024-08-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-02 | 2024-08-09 | 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 | 2024-07-02 | 2024-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-02 | 2024-08-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-02 | 2024-08-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-07-02 | 2024-08-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-02 | 2024-08-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-02 | 2024-08-09 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-07-02 | 2024-08-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-02 | 2024-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-02 | 2024-08-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-07-02 | 2024-08-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-02 | 2024-08-09 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-07-02 | 2024-08-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-02 | 2024-08-09 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-01-08 | 2024-02-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-08 | 2024-02-05 | Y |
| 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 | 2024-01-08 | 2024-02-05 | Y |
| Assess the resident when there is a significant change in condition | Health | 2024-01-08 | 2024-02-05 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-01-08 | 2024-02-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-01-08 | 2024-02-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-08 | 2024-02-05 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-08 | 2024-02-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-01-08 | 2024-02-05 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-08 | 2024-02-05 | Y |
| 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 | 2023-04-20 | 2023-05-16 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-04-20 | 2023-05-16 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-02-09 | 2023-03-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-26 | 2023-02-21 | 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 | 2023-01-26 | 2023-02-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-26 | 2023-02-21 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-01-26 | 2023-02-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-26 | 2023-02-21 | 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 | 2023-01-26 | 2023-02-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-26 | 2023-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-26 | 2023-02-21 | N |
| Post nurse staffing information every day. | Health | 2023-01-26 | 2023-02-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-26 | 2023-02-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-26 | 2023-02-21 | 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 | 2023-01-26 | 2023-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-26 | 2023-02-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-26 | 2023-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-02-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-26 | 2023-02-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-26 | 2023-02-21 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-26 | 2023-02-21 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-26 | 2023-02-21 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-26 | 2023-02-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-01 | 2019-11-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-01 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-01 | 2019-11-22 | N |
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