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Deficiency Records for The Waters of Shelbyville, LLC
A list of the most recent deficiencies for The Waters of Shelbyville, LLC. 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 The Waters of Shelbyville, LLC. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-29 | 2024-01-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-29 | 2024-01-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-08 | 2023-03-24 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2021-11-29 | 2021-12-21 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-11-29 | 2021-12-21 | 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 | 2019-11-05 | 2019-12-18 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-11-05 | 2019-12-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-05 | 2019-12-18 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-11-05 | 2019-12-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-05 | 2019-12-18 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-11-05 | 2019-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-05 | 2019-12-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-06 | 2019-12-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-06 | 2019-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-06 | 2019-12-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-06 | 2019-08-20 | 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 | 2018-12-05 | 2019-01-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-12-05 | 2019-01-15 | N |
| 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 | 2018-12-05 | 2019-01-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-03 | 2019-01-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-03 | 2019-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-03 | 2019-01-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-03 | 2019-01-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-06 | 2018-01-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-12-06 | 2018-01-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-06 | 2018-01-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2017-12-06 | 2018-01-03 | N |
| 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 | 2017-12-06 | 2018-01-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-06 | 2018-01-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-12-04 | 2018-01-03 | 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 | 2017-12-04 | 2018-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-12-04 | 2018-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-04 | 2018-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-12-04 | 2018-01-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-12-04 | 2018-01-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-12-04 | 2018-01-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-12-04 | 2018-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-04 | 2018-01-03 | N |
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