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Deficiency Records for Fair Haven Shelby County
A list of the most recent deficiencies for Fair Haven Shelby County. 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 Fair Haven Shelby County. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-06 | 2024-02-21 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-06 | 2024-02-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-06 | 2024-02-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-10-20 | 2022-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-12-09 | N |
| Dispose of garbage and refuse properly. | Health | 2022-10-20 | 2022-12-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-19 | 2022-12-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-19 | 2022-12-09 | 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 | 2019-11-21 | 2020-03-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-21 | 2020-03-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-21 | 2020-01-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-21 | 2020-01-10 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-21 | 2020-01-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-21 | 2020-01-10 | 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 | 2019-11-21 | 2020-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-21 | 2020-01-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-21 | 2020-01-10 | 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 | 2019-11-21 | 2020-01-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-21 | 2020-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-21 | 2020-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2020-01-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-21 | 2020-01-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-11-21 | 2020-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-21 | 2020-01-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-21 | 2020-01-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-27 | 2018-11-16 | 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 | 2018-09-27 | 2018-11-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-27 | 2018-11-16 | 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 | 2018-09-27 | 2018-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-27 | 2018-11-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Establish methods for sharing information. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-01 | 2018-11-16 | N |
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