Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shelbyville Healthcare & Senior Living during CMS and state inspections, most recent first.
A BOM misappropriated resident trust funds by writing cash checks without resident approval, using resident money for unsupported purchases, and altering or forging signatures on transaction forms. An audit found $12,091.78 in unaccounted-for funds across 21 residents with serious cognitive, psychiatric, and physical diagnoses, and one resident was tearful and said she was not sure who to trust now.
Medication storage and administration failures were observed when an unlocked med cart and improperly secured narcotic box were found in a hallway, and an LPN stated the narcotic box did not lock as expected. In addition, a resident with severe cognitive impairment had mixed morning and evening meds left unattended in the room due to hoarding, and another resident had a cup of pills left unsecured on a bedside table after the DON handed over the meds and left without ensuring they were taken.
Unqualified Director of Food and Nutrition Services: The facility failed to employ a clinically qualified DONS. The Dietary Manager was actively supervising kitchen operations but stated they were not a certified dietary manager, dietician, or otherwise clinically qualified, had only completed a two-day food sanitation course, and did not meet Illinois standards or the listed education and experience requirements. The facility dietician worked remotely on a part-time consulting basis, and 38 residents lived in the facility.
Failure to track and monitor employee illnesses. The IP opened the infection control binder and found resident infection logs and facility illness graphs, but no staff illness log. She stated the facility did not document employees’ signs and symptoms or the type of illness, and she was only aware of nursing staff illnesses through call offs. The DON produced a nursing call-off list that included names and dates only, with no illness details, and stated it was the only documentation available for monitoring employee illness. The Administrator stated the IP should be monitoring and tracking all staff illness and/or signs and symptoms of illness.
Failure to offer staff COVID-19 vaccinations and document staff vaccination status. The Infection Preventionist stated the facility does not offer COVID vaccines to staff and does not track staff vaccination status. Record review showed 38 residents were residing in the facility.
PASARR screening was not completed for two residents reviewed. One resident had a prior PASARR Level II that became outdated after a new major depression diagnosis was added, and a new Level I screening was not completed. Another resident had multiple psychiatric diagnoses and severe cognitive impairment, but the EMR did not document a PASARR Level I or Level II screening; staff stated a requested Level I was withdrawn and no follow-up was documented.
Failure to perform hand hygiene and disinfect a PICC access device occurred when the DON entered a resident’s room, donned gloves without cleaning her hands, stopped an IV pump alarm, and flushed the resident’s PICC with saline and heparin without sanitizing the needleless access device. She then removed her gloves and left without sanitizing her hands. The DON stated hand hygiene should be done before gloves and the access device should be disinfected before flushing the PICC.
Insufficient room size for resident beds: multiple rooms on the 100, 200, and 300 halls did not meet the required square footage per bed, affecting 33 residents. Residents reported the rooms were too small and lacked space for belongings, and the ADM and Regional RN acknowledged that the facility had rooms that were not regulatory size.
A resident with severe cognitive impairment and total dependence on staff developed skin tears on the left lower back and hip due to improper handling during incontinence care. The wounds were not promptly treated, as verbal orders were delayed in being entered, and the care plan was not updated to address the new injuries. Required incident reporting and risk management documentation were also not completed, contrary to facility policy.
Multiple residents with cognitive impairment and behavioral disturbances were involved in incidents where one resident physically abused another, including grabbing and slamming a hand onto a table and striking another on the hand. Staff did not consistently implement care plan interventions, such as moving agitated residents to calm areas, and the facility failed to prevent these abusive interactions despite known behavioral risks.
Two residents with complex medical conditions did not receive physician-ordered wound care due to the facility's failure to transcribe and implement orders, provide necessary supplies, and notify providers of changes or issues. One resident's wounds worsened, leading to hospitalization, while another's wound was left untreated and was cross-contaminated during a dressing change by an LPN.
The facility did not have a full-time DON on staff for an extended period, leaving an LPN and other staff to manage multiple roles and responsibilities. The administrator confirmed the DON position had been vacant, and staff reported difficulty keeping up with duties and monitoring resident care programs.
Four residents with open wounds or draining lesions did not have Enhanced Barrier Precautions (EBP) implemented as required. Care plans lacked EBP interventions, no EBP signage or PPE was present outside rooms, and staff provided wound care without gowns. Staff interviews revealed a lack of awareness and monitoring of EBP, despite facility policy requiring its use for residents with open wounds.
A resident with extensive lower extremity wounds and heavy drainage was required by staff to wear garbage bags over his legs and plastic booties to contain wound drainage, due to facility budget constraints and staffing limitations. The resident was told he could not leave his room without the bags, leading to embarrassment and a lack of dignity. An LPN acknowledged this was not the appropriate method and that dressings should have been changed instead.
Two residents reported that an LPN was often rude and dismissive, affecting their sense of dignity. One resident described the LPN as pushy and having a bad attitude, particularly when needing assistance at night. Another resident noted the LPN's dismissive behavior when requesting to smoke, which was discussed in a Resident Council Meeting without follow-up. Both residents felt safe but undeserving of such treatment.
A resident with dementia was involved in an altercation with a CNA, resulting in physical abuse. The CNA, who lacked proper training, attempted to redirect the resident to her room, leading to the resident falling and sustaining bruises. The CNA admitted to being overwhelmed and acknowledged the need for assistance in deescalating the situation. The facility's failure to provide adequate training and support contributed to the deficiency in ensuring resident safety.
The facility failed to report concerns from a Resident Council Meeting about an LPN's poor demeanor towards residents. Despite the facility's policy requiring immediate reporting of potential mistreatment, the concerns were not communicated to the Administrator, preventing an investigation. Interviews with two residents confirmed the lack of follow-up on the issue.
The facility did not provide an RN for at least 8 consecutive hours a day, 7 days a week, for 10 days within a 39-day period, affecting 25 residents. The nurse assignment sheets for July and August 2024 showed missing RN coverage on specific dates, particularly on weekends. The DON confirmed the lack of RN coverage during weekends.
A resident's right to formulate advanced directives was not honored, as their wish to be a DNR was not documented in their medical record. Despite expressing a desire not to be resuscitated, the resident's records lacked a signed DNR, resulting in them being treated as a full code. The facility's policy required documentation of such decisions on the day of admission, which was not followed.
A resident in a LTC facility experienced a failure in maintaining a safe and homelike environment. The resident's room had a 10-inch hole with crumbling plaster and a ceiling with water stains and bulging plaster due to previous leaks. Despite the resident's cognitive awareness and complaints, the issues persisted for two years. The Maintenance Director acknowledged the problem, citing a lack of funds from corporate to address the repairs, contrary to the facility's policy of ensuring a well-maintained environment.
A resident with COPD experienced facial skin irritation due to the facility's delay in replacing their Bi-PAP mask. Despite the resident's reports of needing mask liners to prevent irritation, the facility failed to follow up on the order promptly. The DON acknowledged the issue and reordered the mask, admitting the original order should have been addressed sooner.
A resident with severe cognitive impairment and a history of elopement did not receive a departure alert system safety bracelet for twelve days after an elopement incident. Despite being at high risk, the necessary safety device was not ordered, and the resident continued to wander without adequate supervision. Staff acknowledged the oversight, and the facility's Elopement Prevention Policy was not effectively followed.
The facility failed to implement timely infection control measures for a resident with an ESBL infection, leading to inadequate precautions and PPE use. Despite the diagnosis, the resident was not isolated immediately, and their roommate was not moved, allowing shared bathroom use. A CNA provided care without proper PPE due to a lack of awareness, and there were no designated trash receptacles for soiled PPE, indicating a failure to adhere to infection control protocols.
The facility failed to provide the required minimum of 80 square feet per resident bed, affecting 23 residents. Historical documentation and measurements showed that certain rooms only provided 73 to 78 square feet per bed. The Administrator acknowledged the issue, stating it recurs annually, requiring a waiver application process. All 80 beds are certified under Medicare or Medicaid.
Misappropriation of Resident Trust Funds by Business Office Manager
Penalty
Summary
The facility failed to protect residents from misappropriation of property by a staff member, affecting 21 of 21 residents reviewed for resident trust fund concerns. The report states that a Business Office Manager began writing checks for cash without resident approval and that resident trust funds were used without supporting documentation. The facility’s audit identified $12,091.78 in resident trust money that could not be supported by receipts or verified spending, and the discrepancies involved transactions spanning from 9/30/25 through 4/15/26. The records and interviews describe that the Business Office Manager had residents sign forms and then took cash out, used resident trust money for other people, and could not account for where most of the cash was spent. The same staff member stated that R15’s money was used to purchase a television that R15 did not have in possession, and that receipts were not available for all monies spent. The Regional Administrator stated that the staff member was forging resident signatures and altering requested amounts with whiteout. The residents affected were vulnerable adults with diagnoses including dementia, Alzheimer’s disease, schizoaffective disorder, intellectual disability, bipolar disorder, depression, anxiety, schizophrenia, cerebral palsy, and other serious medical and psychiatric conditions. The audit documented unaccounted-for cash transactions for each of the 21 residents, including multiple transactions for some residents and significant missing amounts for others. One resident was described as very tearful and stated she was not sure who to trust now.
Medication Storage and Administration Failures
Penalty
Summary
The facility failed to ensure medications were properly labeled, stored in locked compartments, and kept in a locked environment. During observation, a medication cart in a resident hallway was left unlocked, and the narcotic box inside was not locked in place. An LPN stated she had opened the narcotic box for the previous resident and thought it would lock when the drawer was closed, but it did not. On another cart, an LPN unlocked the narcotic box and then closed the drawer, and when the drawer was reopened the narcotic box was still not locked. A regional RN stated she did not know the carts were not locking correctly and said she would call the pharmacy to have them fixed or replaced. The facility policy stated medication compartments are to be locked when not in use and controlled substances are to be separately locked in permanently affixed compartments. The facility also failed to ensure medications remained secured during administration. A medicine cup containing nine medications was found unattended on a resident’s bedside dresser, including medications ordered for different times of day. The DON stated the resident was known to hoard medications and that nurses do not stay with the resident as they should, allowing the resident to mix morning and evening medications. The resident’s record showed severe cognitive impairment and multiple scheduled medications, including Divalproex ER, Rosuvastatin, Mirtazapine, Glipizide, Apixaban, Metformin, Benadryl, and Gabapentin. In another room, a medicine cup containing six pills was left on a bedside table and accessible to others, and the DON stated she handed the cup to the resident and left the room without ensuring the medications were taken.
Unqualified Director of Food and Nutrition Services
Penalty
Summary
Employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietician, was not met because the facility failed to employ a clinically qualified Director of Food and Nutrition Services. On 2/17/2026 at 9:35 AM, the Dietary Manager (V10) was observed actively supervising dietary operations in the facility kitchen and stated that they were the full-time manager of the food service operation. V10 reported not being a clinically qualified Certified Dietary Manager, not having equivalent training, and not meeting Illinois standards to be a food service manager or dietary manager. V10 also reported completing only a two-day food service sanitation course that did not include clinical nutrition instruction and denied having any qualifications in clinical nutrition. V10 stated the facility dietician works remotely on a part-time consulting basis and does not work directly in the facility. V10 denied being a dietician, being a certified dietary manager, having an associate's or higher degree in food service management or hospitality, having two or more years of experience as a director of food and nutrition services in a nursing facility, or meeting any of the other listed education and experience qualifications. The facility assessment stated the facility would employ a Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services, and the Midnight Census Report dated 2/18/2026 documented 38 residents in the facility.
Failure to Track and Monitor Employee Illnesses
Penalty
Summary
The facility failed to track and monitor employee illnesses. On 02/18/2026 at 11:20 AM, the Infection Preventionist opened the Infection Control binder and it contained resident infection logs and facility illness graphs, but no logging of staff illness. She stated the facility did not document the signs and symptoms employees were experiencing when sick or the type of illness if known, and that she was only aware of nursing staff illnesses through call offs. She also stated she was not aware of illnesses for other departments working in the facility. The Director of Nursing then produced a binder with a list of nursing staff call offs from September 2025. That list documented staff names and dates, but did not document the type of illness or the signs and symptoms of illness. The DON and Infection Preventionist stated this was the only documentation they had for tracking and monitoring employee illnesses. On 2/19/26, the Administrator stated the Infection Preventionist should be monitoring and tracking all staff illness and/or signs and symptoms of illness. The facility policy titled Communicable/Contagious Diseases, Employee, dated December 2024, states the Infection Preventionist is responsible for oversight of staff illnesses. The facility application for Medicare and Medicaid dated 2/17/26 documented 38 residents in the facility.
Failure to Offer and Document Staff COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer staff COVID-19 vaccinations and failed to document staff vaccination status. During an interview on 02/18/2026 at 11:20 AM, the Infection Preventionist stated that the facility does not offer staff COVID vaccinations and does not keep track of staff vaccination status. Record review of the facility's Long Term Care Facility Application for Medicare and Medicaid, dated 2/17/26 and signed by the Regional Registered Nurse, documented that there were 38 residents residing in the facility.
Failure to Complete PASARR Screening for Two Residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for two residents reviewed. One resident, R13, had a PASARR Level II screening dated 12/13/24 that stated a Level II was not indicated because there was no evidence of a serious behavioral health condition, but it also noted that if changes occurred or new information refuted those findings, a new Level I screening had to be submitted. R13's medical diagnoses list dated February 2026 documented a new diagnosis of Major Depression added in November 2025, and the Regional Clinical Nurse confirmed that this new mental illness diagnosis meant a new PASARR Level I assessment should have been completed. Another resident, R6, had diagnoses documented in the EMR including Psychotic Disorder with Hallucinations, Violent Behavior, Psychotic Disturbance, Mood disturbance, Anxiety, Depression, and Major Depressive Disorder, and the MDS documented severe cognitive impairment. The EMR did not document a PASARR Level I or Level II screening. Although an Interagency Certification of Screening Results dated 1/26/2024 documented supportive living services were appropriate, the Regional Clinical Nurse stated the facility had requested a Level I PASRR but the organization that completes the facility's PASRRs withdrew the request, and the facility should have followed up to determine why the testing date was withdrawn and obtained a Level I PASRR for R6.
Failure to Perform Hand Hygiene and Disinfect PICC Access Device
Penalty
Summary
The facility failed to perform hand hygiene and to sanitize a needleless access device before flushing a PICC line for one resident reviewed for infection control. During an observation in the resident’s room, the DON entered, put on gloves without washing or sanitizing her hands, and while wearing the same gloves pushed a button on the resident’s IV pump to stop a beeping noise. She then flushed the resident’s PICC with a prefilled saline flush and followed with a heparin flush without sanitizing the needleless access device. After finishing, she removed her gloves and left the room without sanitizing her hands. When interviewed, the DON stated hand hygiene should be performed before putting on gloves and the needleless access device should be sanitized before flushing a PICC line. The facility’s Central Venous Catheter Care and Dressing Changes Policy dated 2001 documents hand hygiene before gloves and disinfection of the needleless access device before flushing the PICC line.
Insufficient Room Size for Resident Beds
Penalty
Summary
The facility failed to provide a minimum of 80 square feet of floor space per resident bed in multiple rooms. The deficiency affected 33 residents, including R2-R6, R8, R10, R13-R20, R22-R30, R32-R35, R37, R38, R40, R49, and R50, who were identified on the facility daily Midnight Census Report as residing in undersized rooms. Historical room size documentation and actual measurements showed that rooms 101 through 111 and 201 through 210 provided 73 square feet per resident bed, and rooms 301 through 311 provided 78 square feet per resident bed. During interviews, residents stated their rooms were too small. R35 and R29, who were roommates, both said their room was too small, and R29 said it would be nice to have a larger room to have more room to move around. R13 and R14, who were roommates, both said they did not have enough room for their belongings, and R13 stated they had a lot of items with nowhere to put them and had to stack their belongings because there was no room for extra tables. The Administrator stated the facility had rooms that were not regulatory size, that any resident could be housed in any room, and that all rooms on the 100, 200, and 300 halls were too small. The Regional RN stated the facility had always gotten the room size tag because the facility has rooms that are too small.
Delayed Treatment and Care Plan Update for Facility-Acquired Skin Tears
Penalty
Summary
The facility failed to provide timely treatment for a resident's left lower back and left hip skin tears, and did not update the resident's skin care plan to reflect these new wounds. The resident, who was documented as severely cognitively impaired and dependent on staff for all activities of daily living, acquired the skin tears at the facility due to staff pulling too hard on incontinence briefs or linens, causing a shearing effect. The wounds were first noted by the wound nurse and physician assistant during rounds, and although verbal treatment orders were received, they were not entered until several days later when written orders were provided. As a result, there was a delay in initiating the prescribed wound care treatments. Additionally, the resident's care plan was not updated to include interventions for the newly acquired skin tears, and no incident report or risk management documentation was completed regarding the injuries. Facility policy requires prompt assessment, documentation, and treatment orders for new skin conditions, as well as updates to care plans and incident reporting. These steps were not followed, resulting in a lack of timely intervention and care plan revision for the resident's skin injuries.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents involving four residents with cognitive impairments and behavioral disturbances. In one incident, a resident with severe cognitive impairment and a history of aggression became agitated when another resident approached the dining table. The agitated resident grabbed the other resident's hand and slammed it onto the table. Staff present intervened by calmly asking the aggressive resident to release the hand, which was done, and the incident was reported to the charge nurse. The care plan for the aggressive resident included interventions to move the resident to a calm area when agitated, but on this occasion, the resident was taken to the dining room, which was noted by staff as a noisy environment not suitable for calming the resident. Another incident involved a resident with cognitive impairment and behavioral disturbances striking another resident on the hand when the latter approached the table. Both residents involved had care plans addressing their behavioral issues, including interventions for aggression and wandering. The incident was documented in the facility's incident report, and staff were aware of the behavioral risks associated with these residents. The facility's Abuse Prevention Program policy affirms residents' rights to be free from abuse and outlines procedures for removing residents who allegedly abuse others from contact during investigations. However, in these cases, the facility did not effectively implement interventions or environmental controls to prevent resident-to-resident physical abuse, despite documented behavioral risks and care plan interventions for the residents involved.
Failure to Implement Physician-Ordered Wound Care and Prevent Cross-Contamination
Penalty
Summary
The facility failed to transcribe and implement physician-ordered wound treatments, did not ensure the provision of necessary wound supplies, and did not complete treatments as ordered for a resident with multiple complex medical conditions, including lymphedema, chronic venous hypertension with ulcers, diabetes, and cellulitis. The resident experienced pain, embarrassment, and worsening of bilateral lower extremity wounds, ultimately resulting in a 15-day hospitalization for wound treatment and infection. The facility did not accommodate the resident's request for alternative wound treatments, failed to notify the wound physician assistant (PA) of changes or issues with dressing orders, and did not document or implement updated wound care plans. Staff used inappropriate materials, such as garbage bags, to manage wound drainage, and failed to provide the correct dressings due to cost concerns, leading to further deterioration of the resident's wounds. Another resident with a history of morbid obesity, chronic obstructive pulmonary disease, heart failure, peripheral vascular disease, and lymphedema had open sores on the left elbow that were not assessed, monitored, or reported to the physician in a timely manner. No treatment orders were obtained for the wound, and the area was left without a protective dressing for several days despite staff awareness. During a wound care observation, a licensed practical nurse (LPN) cross-contaminated an open draining wound by reapplying a piece of calcium alginate rope that had fallen onto a soiled towel back onto the resident's wound, acknowledging that this could cause infection. The facility's own policies required prompt assessment, documentation, physician notification, and treatment order acquisition for new skin lesions or wounds, as well as adherence to physician orders for dressing changes. These protocols were not followed, resulting in unaddressed wounds, improper wound care practices, and lack of communication with medical providers regarding changes or issues with wound management.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), as required, which affected the oversight of care for all 37 residents. According to the facility's census report, 37 residents were present during the survey period. Observations and interviews revealed that there was no DON present in the facility from early February 2025 through the survey dates. The administrator confirmed that the DON position had been vacant since early February, acknowledging the importance of the DON in maintaining quality of care. Additionally, a wound nurse/LPN/infection preventionist reported difficulty managing her multiple roles and responsibilities, indicating that the absence of a DON contributed to challenges in addressing resident concerns and monitoring facility programs.
Failure to Implement Enhanced Barrier Precautions for Residents with Open Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four out of five residents reviewed, all of whom had open wounds or conditions requiring wound care. For each of these residents, care plans did not document a focus area, goal, or interventions related to EBP. Observations revealed that there were no EBP signs posted on the residents' doors, and no Personal Protective Equipment (PPE) such as gowns or gloves was available outside their rooms. Staff, including an LPN and the Infection Preventionist, provided wound care without wearing gowns, and both later acknowledged that EBP should have been used. In one instance, a resident with open sores on both feet was found with exposed toes resting on a dirty floor, and staff reportedly only wore gloves, never gowns, during dressing changes. Interviews with staff confirmed a lack of awareness and implementation of EBP, with the Infection Preventionist stating she was unaware of EBP requirements until after the surveyor's inquiry. The facility's own policy required EBP for residents with open wounds needing dressing changes, specifying the use of gowns and gloves during high-contact care activities. Despite this, EBP was not monitored, tracked, or applied to residents who met the criteria, and there was no evidence of physician orders or care plan interventions for EBP in the medical records reviewed.
Failure to Ensure Resident Dignity in Wound Care Management
Penalty
Summary
A resident with multiple complex medical conditions, including lymphedema, chronic venous hypertension with ulcers, diabetes mellitus type II, Parkinson's disease, cellulitis, morbid obesity, chronic kidney disease, acute kidney failure, and chronic congestive heart failure, was found to have significant wounds on both lower extremities and feet. The wounds were described as macerated, with heavy serosanguinous drainage and associated pain. The resident was cognitively intact and required supervision with bathing and footwear. The care plan instructed staff to keep the resident's skin clean and dry and to follow facility protocols for skin breakdown prevention and treatment. Despite these instructions, staff directed the resident to wear garbage bags over his lower legs and plastic booties to contain the drainage, citing a lack of budget to re-wrap the legs multiple times per day. The resident was told he could not leave his room unless he wore the garbage bags, and staff used gauze to tie the bags in place. The resident expressed embarrassment about this practice, stating it was done to prevent drainage from soiling the floors and because staff did not have time to clean up after him. The wound nurse acknowledged that this was not the best method and that dressings should have been changed instead. This practice failed to ensure the resident's dignity and did not promote his quality of life as required by resident rights.
Failure to Treat Residents with Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the interactions between an LPN and two residents. The residents, who were cognitively intact, reported that the LPN was often rude and dismissive in her interactions with them. One resident described the LPN as having a bad attitude and being pushy, particularly when the resident needed assistance at night. The resident felt that the LPN's demeanor changed the atmosphere in the room and expressed dissatisfaction with being treated poorly, although they did not feel physically abused. Another resident reported similar experiences, stating that the LPN was rude and dismissive when the resident requested to go outside for a smoke. The resident noted that the LPN's behavior was discussed in a Resident Council Meeting, but no follow-up occurred regarding the concerns raised. Both residents expressed feeling safe in the facility but felt that the LPN's behavior was inappropriate and undeserving, especially from someone in a position of authority.
Resident Safety Compromised Due to Inadequate Staff Training and Handling
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, resulting in a deficiency. The resident, who has medical diagnoses including dementia and severe cognitive impairment, was involved in an altercation with a Certified Nursing Assistant (CNA). The incident occurred when the resident became agitated with other residents at a dining room table, and the CNA attempted to redirect the resident to her room. During this process, the resident attempted to stand up, and the CNA grabbed her arm, resulting in the resident falling and sustaining bruises. The CNA involved in the incident was on probation and was later terminated due to poor attitude and performance. The CNA admitted to being overwhelmed and frustrated, acknowledging that she should have sought assistance from other staff members to deescalate the situation. The CNA also admitted to not having received any dementia or abuse training from the facility, which contributed to her inability to handle the situation appropriately. The Director of Nursing (DON) and other staff members assessed the resident's injuries, noting bruises on the resident's arm consistent with the CNA's account of the incident. The resident repeatedly mentioned the bruising and expressed that the CNA had pushed her down. The facility's failure to provide adequate training and support for the CNA, as well as the inappropriate handling of the resident's behavior, led to the deficiency in ensuring the resident's safety from abuse.
Failure to Report Resident Concerns About LPN's Demeanor
Penalty
Summary
The facility failed to report concerns raised during a Resident Council Meeting regarding the demeanor of a night nurse, identified as an LPN, towards residents. The facility's policy requires employees to immediately report any potential mistreatment or abuse to a supervisor and the Administrator. However, the concerns about the LPN's poor demeanor, discussed in the January Resident Council Meeting, were not reported to the Administrator as required. The minutes from the meeting documented these concerns, and the staff liaison present was the previous Activity Director. Interviews with two residents revealed that they discussed the LPN's poor demeanor during the meeting, but no follow-up occurred. One resident mentioned that typically someone would address concerns raised in meetings, but this time no one approached them. The Administrator in Training was unaware of the concerns documented in the meeting minutes and stated that the previous Activity Director should have reported the issue immediately to initiate an investigation. This lack of reporting and follow-up led to a deficiency in the facility's handling of potential abuse allegations.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 10 days within a 39-day period. This deficiency affected 25 residents residing in the facility. The review of the facility's nurse assignment sheets for July and August 2024 revealed that there was no RN coverage for the required hours on specific dates, including weekends. The Director of Nurses confirmed the lack of RN coverage during weekends, acknowledging the deficiency in meeting the regulatory requirement for RN staffing.
Failure to Honor Resident's Advanced Directives
Penalty
Summary
The facility failed to honor a resident's right to formulate advanced directives, affecting one resident out of 16 reviewed for advanced directives. The resident, identified as R179, expressed a desire not to be resuscitated, stating that they were in constant pain and did not wish to be brought back to life. Despite this, R179's Electronic Medical Record did not include any information about their wishes or election of advanced directives, and the resident was admitted to the facility without this documentation. A Licensed Practical Nurse (V3) confirmed that there was no signed DNR (Do Not Resuscitate) order in R179's records, meaning the resident would be treated as a full code until a signed DNR was obtained. The Social Services Director (V11) acknowledged that R179 wanted to be a DNR with select treatment and had taken the necessary form to the doctor for signature. However, the process of obtaining the signed form was delayed, leaving R179's code status as full code in the absence of a signed POLST (Practitioner Ordered Life Sustaining Treatment) form. The facility's policy required that any decision made by the resident be indicated in the chart on the day of admission, which was not adhered to in this case.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for a resident, identified as R14, who was cognitively intact with a Brief Interview of Mental Status score of 14 out of 15. During an observation, a 10-inch unpainted hole with crumbling plaster was found between the head of R14's bed and the bedside dresser. R14 reported that the hole had been present since their admission to the facility two years ago. Additionally, R14 mentioned a ceiling in disrepair due to previous rain leaks, which had been addressed by removing a plastic bag from the gutter, but the ceiling remained damaged. Further inspection revealed a three-foot-long section of the ceiling with dark brown water stains and bulging plaster at the wall and ceiling junction. The wall below had chipped plaster and water marks. The Maintenance Director confirmed the ongoing issues, stating that the roof had been repaired three years ago, but the area continued to be problematic. Despite corporate awareness, funds had not been released to fix the damage. The facility's policy emphasizes the importance of maintaining a safe and hospitable environment, but the necessary repairs had not been completed in a timely manner.
Delayed Replacement of Bi-PAP Mask Leads to Skin Irritation
Penalty
Summary
The facility failed to replace a resident's Bi-level Positive Airway Pressure (Bi-PAP) mask in a timely manner, resulting in facial skin breakdown. The resident, who has Chronic Obstructive Pulmonary Disease (COPD) and uses a Bi-PAP mask nightly, was observed with raw, red, bumpy, and irritated skin around the mouth, nose, and chin. The resident, who has no cognitive impairment, reported that they had informed the nursing staff about the need for mask liners to prevent skin irritation, and the issue was communicated to the Administrator and the Director of Nursing (DON). Despite the resident's reports, the facility did not follow up promptly on the order for a new Bi-PAP mask. The DON acknowledged the resident's skin condition and stated that the medical supply company indicated the mask had already been received by the facility, but it could not be located. The DON reordered the mask for overnight delivery, admitting that the original order should have been followed up sooner. The delay in replacing the mask led to the resident's skin irritation, which was not addressed in a timely manner.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement a departure alert system safety bracelet for a resident, identified as R129, who was at high risk of elopement. R129 had a history of elopement from home and was diagnosed with severe cognitive impairment, unsteady gait, and wandering behaviors. Despite these risks, the resident did not receive the necessary safety bracelet for twelve days following an elopement incident on 7/26/24, during which the resident exited the facility but was redirected back inside without difficulty. The deficiency was further highlighted by multiple observations and staff interviews. On 8/6/24, R129 was seen wandering independently without a safety bracelet, and staff confirmed the resident's exit-seeking behavior. The Director of Nursing acknowledged the need for a bracelet and admitted that the order for the device had not been placed, contrary to initial assumptions. The Administrator later confirmed that the document provided was merely a quote and not an actual order for the bracelet. The facility's Elopement Prevention Policy mandates assessing residents for elopement risk and implementing preventive interventions. However, the only intervention planned for R129 post-elopement was the safety bracelet, which was not provided in a timely manner. Staff members, including the LPN and housekeeper, reported the resident's wandering and exit attempts, emphasizing the need for the bracelet, which was not available in the facility at the time.
Inadequate Infection Control Measures for ESBL Infection
Penalty
Summary
The facility failed to implement timely infection control precautions for a resident diagnosed with an ESBL infection in the urine. Despite the diagnosis on 08/04/24, the resident was not placed on contact isolation immediately, and their roommate was not moved to another room until later. The delay in implementing these precautions allowed both residents to continue using the same bathroom, increasing the risk of cross-contamination. Additionally, there was a lack of appropriate signage indicating contact isolation precautions, and no PPE supplies were set up outside the residents' room. Staff members did not adhere to infection control protocols during direct care. A CNA provided a shower to the resident with ESBL without wearing the required PPE, such as a gown and eye protection, due to a lack of awareness about the resident's infection status. The CNA only wore gloves, which was insufficient given the potential for urine splashing. This oversight was compounded by the absence of designated trash receptacles for discarding soiled PPE, further compromising infection control measures. The facility's policy on PPE use and infection control was not effectively implemented. The policy requires clear signage, availability of PPE, and proper staff training on PPE use. However, these measures were not in place, as evidenced by the lack of PPE supplies and inadequate staff awareness. The infection preventionist acknowledged the need for PPE during personal care, but the failure to ensure compliance with these protocols contributed to the deficiency.
Failure to Provide Minimum Required Room Size
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of floor space per resident bed, affecting 23 residents. Historical room size documentation and actual measurements revealed that rooms 101 through 111, 201 through 210, and 301 through 311 do not meet the required space, providing only 73 to 78 square feet per resident bed. The facility's Declaration of Room Sizes, revised on 8/1/21, confirms these deficiencies. The Administrator acknowledged awareness of the undersized rooms, stating that the issue recurs annually, necessitating a waiver application process. The Medicare/Medicaid Certification and Transmittal from the most recent annual survey on 7/19/2023 confirms that all 80 beds in the facility are certified under Title 18 (Medicare) or Title 19 (Medicaid).
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shelbyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shelbyville Manor | 0.8 mi | ★★★★★ | 9 | 0 |
| Pana Health And Rehab Center | 15.1 mi | ★★★★★ | 1 | 0 |
| Rose Garden Of Pana | 15.5 mi | ★★★★★ | 11 | 0 |
| Sullivan Healthcare & Senior Living | 15.9 mi | ★★★★★ | 15 | 0 |
| Eastview Healthcare & Senior Living | 17.3 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.