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Deficiency Records for Willows of Shelbyville
A list of the most recent deficiencies for Willows of Shelbyville. 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 Willows of Shelbyville. 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 each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-05-02 | 2024-05-20 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-05-02 | 2024-05-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-02 | 2024-05-20 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-22 | 2024-03-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-22 | 2024-03-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-22 | 2024-03-20 | Y |
| 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 | 2024-02-22 | 2024-03-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-22 | 2024-03-20 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Meet other general requirements. | Fire Safety | 2023-08-14 | 2023-10-31 | 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 | 2023-08-14 | 2023-10-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-14 | 2023-10-31 | 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 | 2023-08-14 | 2023-10-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-14 | 2023-10-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-26 | 2023-08-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-26 | 2023-08-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-07-26 | 2023-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-26 | 2023-08-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-26 | 2023-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-26 | 2023-08-25 | 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 | 2023-07-26 | 2023-08-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-26 | 2023-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-26 | 2023-08-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-26 | 2023-08-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-09-23 | 2022-10-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-23 | 2022-10-14 | Y |
| Meet other general requirements. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-08 | 2022-07-15 | 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 | 2022-06-08 | 2022-07-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2022-06-08 | 2022-07-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-25 | 2022-06-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-25 | 2022-06-02 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-25 | 2022-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-25 | 2022-06-02 | 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 | 2022-04-25 | 2022-06-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-25 | 2022-06-02 | Y |
| 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 | 2019-07-25 | 2019-08-22 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-07-25 | 2019-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-17 | 2019-07-04 | 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 | 2019-06-17 | 2019-07-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-17 | 2019-07-04 | 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 | 2019-06-17 | 2019-07-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-17 | 2019-07-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-06-17 | 2019-07-04 | N |
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