Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shelbyville Manor during CMS and state inspections, most recent first.
A resident with osteoporosis, spinal fractures, and a right ankle fracture was ordered to wear a TLSO brace whenever out of bed and to use ankle support with a surgical shoe. The resident was observed without the brace while seated in a recliner, reported severe pain when the brace was off, and said staff had repeatedly removed it after transfers. A CNA said they did not know the brace had to stay on out of bed, and the RN and MD confirmed the ordered supports were required.
A resident with severe dementia and a history of falls ambulated to the restroom without a walker, fell while trying to grab a bathroom door handle, and sustained a hand laceration requiring ER care and 15 sutures. Surveyors found the bathroom door handle had a detached metal cover with sharp edges and exposed components, and staff stated the handle had been broken for months and was not repaired before the injury.
A facility failed to conduct abuse risk assessments and to implement care-planned non-pharmacological interventions for several cognitively impaired residents with dementia and behavioral disturbances. One resident with severe cognitive impairment was struck on the face by another cognitively impaired resident, yet neither had documented abuse risk assessments. Another resident with Alzheimer’s disease and behavioral disturbance repeatedly engaged in sexually inappropriate and intrusive behaviors toward staff and female residents, including grabbing buttocks and breasts, exposing genitals, entering or attempting to enter female residents’ rooms, and touching or attempting to touch female residents while seated or asleep. Documentation showed that staff responses were often limited to verbal redirection, reminders that behavior was inappropriate, monitoring, and basic assistance with clothing or hygiene, with no consistent evidence that the broader, individualized non-pharmacological interventions listed in the care plan were implemented. A severely cognitively impaired resident was also identified as an alleged victim of breast touching by this behaviorally disturbed resident. Facility staff and leadership acknowledged that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that no specific abuse risk assessment tool was used, despite an abuse prevention policy requiring identification of residents at risk of abusing others or being victims and inclusion of appropriate interventions on care plans.
A resident with CKD, diabetes, chronic pain, and morbid obesity, who was cognitively intact and dependent on staff for ADLs, was care planned to receive showers twice weekly with attention to drying skin folds. Shower records for a given month showed the resident received only four showers and missed two scheduled showers, with no documentation of refusals. The resident reported that staff frequently forgot to provide showers and that she often had to remind them, while the DON confirmed the resident was scheduled and care planned for two showers per week and had missed two showers during that month.
Two residents with dementia, neurological conditions, and multiple psychoactive and anti-seizure medications experienced repeated falls related to inadequate implementation of fall-prevention measures. For one resident, the care plan contained conflicting directions about wheelchair foot pedals, and an intervention to add non-slip material to the wheelchair seat was not documented or in place during observation. For another resident with a history of falls, documentation showed inconsistent or missing information about footwear, and the resident was later observed in a wheelchair wearing regular socks with a foot dangling between foot pedals, despite staff stating that non-slip socks were needed and that the resident attempted to stand without assistance.
A resident with dementia, multiple vitamin deficiencies, and documented dental issues had a physician order for a high‑protein supplement TID with meals and a recorded dislike of chicken. During a lunch meal, the resident was served chicken cordon bleu and did not receive the ordered high‑protein milkshake, even though both the supplement order and the chicken dislike were clearly printed on the diet ticket. The resident reported inconsistent receipt of the milkshakes and reiterated his dislike of chicken, while a CNA, the Dietary Manager, and the DON each confirmed that the meal and supplement provided did not match the documented physician orders and stated food preference.
Two residents with cognitive impairment and high fall risk experienced multiple falls due to the facility's failure to update care plans with appropriate interventions, lack of documentation of required 15-minute checks, and incomplete fall investigations. Staff did not consistently document or implement fall prevention measures, and leadership confirmed the absence of policies for tracking interventions or collecting witness statements.
Several hot water heaters located in resident closets were found with visible mold, rust, and lime build-up, with resident clothing hanging directly above or touching the units. Staff and family members had reported concerns about these unsanitary conditions, but the issues remained unaddressed, and there was no documentation of the concerns in the affected residents' records.
A resident with cognitive impairment and a history of falls was consistently placed in bed with full-length body pillows and a concave mattress to prevent bed exit, but the facility failed to assess or care plan these devices as restraints. Despite multiple falls and a resulting pelvic fracture, there was no documentation of restraint assessment or reassessment, and staff confirmed the interventions were used to restrict movement without proper evaluation.
A resident reported that a male CNA was rough during perineal care, resulting in a bleeding skin tear. Staff observed and documented the injury, and the CNA was identified as present on the unit. Despite the report and facility policy requiring suspension, the alleged staff member was not removed from duty and the incident was not reported to authorities.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff failed to prevent both staff-to-resident and resident-to-resident abuse, including a CNA using profanity and physically handling a resident with dementia, and another resident striking a peer with a plastic object, resulting in injury and pain. Prior disciplinary actions for the CNA and inadequate supervision contributed to these incidents.
A cognitively impaired resident with a high fall risk and multiple diagnoses required substantial staff assistance for transfers but was allowed to self-transfer and self-toilet without supervision. The resident fell while attempting to go to the bathroom alone, resulting in fractures that required emergency surgery. Staff were unaware of the resident's true assistance needs, and the care plan did not include targeted interventions to address self-toileting or increased supervision.
The facility did not transmit MDS assessments to CMS within the required time frames for five residents. Documentation and staff interviews confirmed that the assessments were submitted late or not at all, despite established procedures for timely completion and transmission.
Several residents who were diagnosed with severe mental illness after admission did not receive required Level 2 PASRR assessments. Staff misunderstood the requirements, believing Level 2 PASRRs were only needed for new admissions or significant changes, and failed to complete them when new mental illness diagnoses were made.
Staff failed to follow proper infection control procedures during catheter and incontinence care for multiple residents, including not changing gloves or performing hand hygiene between care tasks, improper cleaning techniques that led to cross-contamination, and not applying barrier cream as required by facility policy.
A resident with severe cognitive impairment and a history of modesty was transported by CNAs to the shower room while inadequately covered, resulting in exposure of multiple body areas in view of other residents and staff. Staff reported undressing the resident in his room for convenience, contrary to facility policy and the resident's known preferences.
A resident with a diagnosis of Major Depressive Disorder with recurrent psychotic symptoms and an Intellectual Disorder was admitted without the facility obtaining a required Level 2 PASRR, despite documentation indicating the need. The administrator reported that Level 2 PASRRs were only being completed after significant changes in status, contrary to facility policy.
A resident with pneumonia and emphysema received oxygen therapy without a complete physician order specifying the flow rate, and a CNA, rather than a licensed nurse, administered the oxygen by turning on the concentrator and setting the rate. The facility's policy requires licensed nurses to administer oxygen and for orders to include all necessary details.
A resident with a history of pain and mobility issues was unable to access her call light and bedside table during the night, resulting in a prolonged period of unmanaged pain. Staff confirmed the items were out of reach, and the nurse did not document the resident's pain level when administering PRN pain medication, contrary to facility policy.
A resident with severe cognitive impairment and multiple behavioral health diagnoses experienced repeated injuries during care due to combative behavior. Staff lacked behavioral health training, and psychiatric services were not in place at the time of the incidents. Injuries were not consistently reported or followed up according to policy, and care plan interventions were not always implemented.
The facility failed to ensure respect and dignity for two residents due to inappropriate communication by a CNA, V4. R2 reported feeling rushed and uncomfortable with V4's demeanor, while R1 felt disrespected and anxious due to V4's frequent room visits and rude manner. Despite the abuse being unsubstantiated, the facility acknowledged V4's inappropriate communication, leading to V4's termination.
A resident with Spastic Paraplegia and other mobility impairments fell from a shower chair when a wheel got caught on the shower curb, resulting in multiple back and neck fractures. The resident required emergency medical treatment and was diagnosed with six vertebral fractures, necessitating pain management and a cervical immobilizer upon return to the facility.
The facility has not employed a Certified Dietary Manager for almost a year, affecting all 80 residents. During a survey, it was confirmed that the position has been vacant for six months, with the Registered Dietician only visiting monthly and reviewing charts remotely weekly. The facility lacks a policy mandating a Certified Dietary Manager, although it is acknowledged that one should be employed.
A facility failed to maintain kitchen equipment in a sanitary condition, risking cross-contamination and food-borne illnesses for 80 residents. Observations included rust and grease buildup on equipment, standing water, and expired food items. Staff confirmed the lack of a cleaning schedule and maintenance issues, violating professional standards for food safety.
A facility failed to maintain resident dignity by not providing timely toileting assistance and allowing staff to engage in personal conversations during meal service. A resident reported waiting long periods for toileting help, leading to incontinence and humiliation. Staff were observed talking about non-work-related topics while assisting residents with severe cognitive impairments during meals, with minimal interaction directed towards the residents. The facility's Administrator acknowledged these as dignity issues.
The facility failed to maintain and store respiratory equipment properly, affecting four residents. Equipment was not dated when changed and was improperly stored, with tubing found on the floor and humidifier bottles on dirty surfaces. Staff confirmed the need for more hygienic practices.
The facility failed to prevent cross-contamination during meal service by not following hand hygiene protocols. A CNA used bare hands to move food on a resident's plate without gloves or hand hygiene, and an LPN assisted two residents without cleaning hands between them. Another CNA handled a resident's drinking cup without hand hygiene. These actions violated the facility's hand washing policy, risking infection spread.
A facility failed to report an allegation of verbal and physical abuse of a resident by a CNA to the Abuse Coordinator. The resident, with multiple medical conditions, was allegedly treated roughly, yelled at, and left in wet clothes. The Administrator was unaware of the incident until later, and the CNA was suspended during the investigation. The facility's policy mandates immediate reporting of such allegations, which was not adhered to.
A resident with Enterocolitis due to Clostridium Difficile did not receive prescribed doses of Fidaxomicin as per physician orders. The MAR showed missed doses on multiple occasions, which was confirmed by an RN. The facility's policy requires adherence to physician orders for medication administration.
A CNA failed to change gloves and perform hand hygiene after contamination with stool while providing catheter care to a resident with multiple medical conditions, including Parkinson's Disease and Bladder-Neck Obstruction. The CNA acknowledged the error, and the IP stressed the importance of proper infection control practices to reduce infection risks.
The facility failed to conduct necessary Psychotropic Medication Assessments for two residents, leading to a deficiency in managing unnecessary medications. One resident with Dementia and Depression had not been assessed in the past year despite being on Citalopram and Olanzapine. Another resident with Depression and Anxiety did not receive an Initial Assessment upon admission while on Buspar and Citalopram. These assessments are essential for the Care Plan and Gradual Dose Reduction Program.
Two residents received meals at a cold temperature due to staff delivering food without covering trays, leading to dissatisfaction and reduced meal consumption. The Nurse Manager acknowledged the lack of a formal policy on covering trays, which contributed to the issue.
A resident with severe cognitive impairment was not served a modified diet as ordered, leading to coughing after consuming un-thickened tomato soup. The CNA feeding the resident and a cook acknowledged the oversight in not thickening the soup, which was required per the resident's dietary order.
Failure to Implement Ordered Post-Fall Brace and Ankle Support
Penalty
Summary
The facility failed to implement post-fall interventions for a resident who had multiple fractures after a fall, including spinal fractures and a right ankle fracture. The resident’s diagnoses included age-related osteoporosis with pathological vertebral fracture, low back pain, long-term anticoagulant use, chronic atrial fibrillation, and hypertension. The resident’s MDS documented a BIMS score of 13 out of 15, indicating no cognitive impairment. After the fall, the resident was sent to a hospital and later returned with orders for a TLSO back brace when up, a surgical shoe for the right ankle fracture, and a compression wrap to the ankle. The resident stated that the back brace was supposed to be worn anytime out of bed and that pain was much worse when the brace was not on. During observation, the resident was seated in a recliner without the back brace in place, and the brace was sitting in a chair nearby. The resident also stated that the ankle wrap and shoe reduced pain, but staff did not consistently apply the wrap. The resident reported that staff had removed the brace after transfers and left the room before it could be put back on, and that this had happened several times with different CNAs. Staff interviews confirmed the inconsistency in carrying out the ordered interventions. A CNA stated the brace was removed during transfer to the recliner and that the CNA did not know the resident had to wear it whenever out of bed. The CNA also stated no one had told them the brace should always remain on and that they had not reviewed the care plan. The RN confirmed the resident should absolutely wear the brace when out of bed, including while seated in the recliner, and noted the ankle wrap being used was not a compression wrap and was positioned too high to support the ankle. The Medical Director confirmed the TLSO brace was to be worn at all times when out of bed and that the compression wrap and surgical shoe were ordered for the ankle fracture. The record also showed the resident received multiple doses of tramadol for pain, but the MAR did not document a pain scale measurement with those doses.
Unsafe Bathroom Door Handle Caused Resident Fall Injury
Penalty
Summary
The facility failed to maintain a safe environment free of an accident hazard when a resident with severe cognitive impairment fell and sustained a hand laceration that required emergency treatment and 15 sutures. The resident had diagnoses including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and a laceration of the superficial palmar arch of the right hand. The resident’s MDS showed a BIMS score of 5, partial/moderate assistance needed for sit-to-stand and toilet transfer, and a history of two prior falls without injury during the look-back period. The care plan identified the resident as at risk for falls related to recent illness/hospitalization, new environment, history of falls, cognitive status, impulsivity, and non-compliance with transfer and ambulation programming, and noted use of a wheeled walker with assistance of one for safety. During the fall event, the resident was observed ambulating to the restroom in the room without the walker, with pants lowered to the knees/ankles and wearing slipper socks. A CNA approached but could not reach the resident in time to prevent the fall. The resident fell to the buttocks and attempted to grab the bathroom door handle while falling, resulting in a large laceration to the inner right hand. The resident was sent to the ER by EMS, where the hand was x-rayed and repaired with 15 sutures, and a tetanus-diphtheria-acellular pertussis injection and lidocaine were administered. The resident later returned to the facility with orders for doxycycline and sutures to the right hand. Survey findings showed confusion and miscommunication about which door caused the injury. Maintenance initially inspected and altered the bedroom door, believing that was the source of the laceration, while the bathroom door was not addressed at that time. Later observation and interviews confirmed the resident had cut the hand on the bathroom door handle. The bathroom door had a detached circular metal cover hanging over the lever handle, exposing inner metal components and sharp knife-like edges. Staff stated the door handle had been broken for months, that the metal piece would slide down when the handle was pulled, and that the hazard had not been fixed before the resident’s fall.
Failure to Implement Abuse Risk Assessments and Non-Pharmacological Interventions for Dementia-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatments, services, non-pharmacological interventions, and abuse risk assessments for residents with dementia and severe cognitive impairment, particularly in relation to resident-to-resident and resident-to-staff incidents. Several residents were identified as having dementia or Alzheimer’s disease with behavioral disturbances, and Minimum Data Set (MDS) assessments documented severe or moderate cognitive impairment. Despite this, the medical records for some residents, including those involved in incidents, did not contain abuse risk assessments to determine whether they were at risk of being victims or perpetrators of abuse. One resident with dementia and severe cognitive impairment was involved in an incident where another cognitively impaired resident put a hand on her face; a CNA witness described the action as the second resident appearing to get mad and smacking the first resident, with apparent contact to the cheek under the eye. Neither resident’s record contained a documented risk assessment for abuse risk as victim or perpetrator. Another resident with Alzheimer’s disease and dementia with behavioral disturbance exhibited a pattern of sexually inappropriate and intrusive behaviors over an extended period, including grabbing the buttocks, breasts, and attempting to kiss CNAs, exposing genitals in public areas, walking naked in hallways, urinating and defecating outside the bathroom, following female residents to their rooms, entering or attempting to enter female residents’ rooms, and attempting or making physical contact with female residents while they were seated or asleep. Nursing progress notes repeatedly documented these behaviors and, in many instances, either documented no intervention or only minimal verbal redirection, reminders that the behavior was inappropriate, or simple monitoring. The same resident’s care plan identified behavioral problems directed at others and an inability to differentiate socially appropriate from inappropriate behaviors, and it listed multiple non-pharmacological interventions such as specific redirection strategies, engagement in activities of interest, and one-to-one supervision. However, there was no documented evidence that staff implemented these listed non-pharmacological interventions beyond repeated verbal redirection, monitoring, and occasional direction to watch a movie or have a snack. Another severely cognitively impaired resident was documented as the alleged victim of breast touching by the behaviorally disturbed resident, and was observed during the survey sitting in the dementia unit day room covered with a blanket, unlike other residents. Multiple staff, including CNAs, RNs, LPNs, and care plan staff, reported either not witnessing the inappropriate behaviors firsthand or only having hearsay knowledge, and facility leadership and care planning staff confirmed that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that the electronic record system did not provide an actual abuse risk assessment. The facility’s own Abuse Prevention policy called for special attention to identifying behaviors that increase a resident’s potential for abusing others or being a victim, and for including appropriate interventions on care plans and communicating them to direct care staff, but the documentation showed that these expectations were not met for the residents involved. Throughout the documented period, the resident with Alzheimer’s disease and behavioral disturbance continued to display sexually inappropriate and intrusive behaviors toward staff and female residents, including repeated touching or attempts to touch staff and residents, making sexual comments, and exposing himself in public areas. Progress notes showed that staff responses were often limited to telling the resident the behavior was inappropriate, redirecting him, assisting with clothing or hygiene after episodes of disrobing or incontinence, or simply monitoring him, with no consistent documentation of the broader, individualized non-pharmacological interventions outlined in the care plan. Additionally, the facility did not document completion of the ordered referral to a geriatric psychiatric hospital for this resident. Social services and care plan staff acknowledged that they were not aware of specific abuse or neglect risk assessment tools being used, and that the existing social history assessment was not designed to evaluate resident-to-resident or staff-to-resident abuse risk, despite the facility’s written policy requiring identification of such risks and inclusion of appropriate interventions on care plans.
Failure to Provide Scheduled Twice-Weekly Showers to Dependent Resident
Penalty
Summary
The facility failed to provide scheduled showers twice weekly to a dependent resident, resulting in missed showers without documented refusals. The resident had chronic kidney disease, diabetes, chronic pain, and morbid obesity, and was cognitively intact with a Brief Interview of Mental Status score of 14 out of 15. The resident’s care plan, initiated on 03/14/2025, specified that the resident was to receive showers twice weekly and requested that staff ensure she was dry and that skin folds were patted dry. Shower documentation for February 2026 showed the resident received showers on 2/3/26, 2/10/26, 2/18/26, and 2/21/26, with no documentation that the resident declined showers between 2/3/26 and 2/10/26 or between 2/10/26 and 2/18/26, indicating two missed showers. The resident reported that staff almost weekly forgot to provide showers, that she often had to remind them, and that sometimes staff did not have time until later in the day, and the DON confirmed the resident was scheduled and care planned for two showers per week and had missed two showers in February 2026. These findings show that the facility did not follow the resident’s care plan and scheduled bathing routine, and did not document any refusals or other reasons for the missed showers, despite the resident’s dependence on staff for activities of daily living and her expectation of two routine showers per week on specific days.
Failure to Implement and Communicate Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and consistently follow fall-prevention interventions as outlined in residents’ care plans. One resident with dementia, multiple neurological conditions, and on numerous psychoactive and anticonvulsant medications had a history of falls from bed and from a wheelchair. After falls in which the resident became entangled with wheelchair foot pedals and struck her head, the interdisciplinary team determined that the wheelchair foot pedals should be removed and non-slip material placed on the wheelchair seat. However, the resident’s care plan contained conflicting information: the Resident Care Information section continued to require bilateral foot pedals on a high-back reclining wheelchair, while the Fall Risk section directed that the foot pedals be removed. The non-slip material intervention was not documented in the care plan. During observation, the resident was transferred into her wheelchair with no non-slip material present on the seat or under the padded cushion, despite the team’s prior decision to use it. A staff member later acknowledged carrying non-slip material intended for this resident’s wheelchair and stated she had revised the care plan to include it, but the care plan still listed foot pedals in one section and removal of foot pedals in another. The staff member also confirmed that the intervention to remove the foot pedals should have been revised in the Resident Care section of the care plan, and the administrator stated that care plan interventions recommended by the interdisciplinary team are expected to be implemented into the care plan. A second resident with encephalopathy, dementia with agitation and psychotic disturbance, Parkinsonism, seizures, osteoporosis, and other conditions, and who was receiving anti-Parkinson’s, antipsychotic, and multiple anti-seizure medications, experienced multiple falls in her room. Documentation showed one fall occurred when the resident was barefoot and looking for a bathroom, another when she was wearing non-skid slippers, and additional falls occurred with an orthopedic boot in place or with no documentation of footwear. Observation later found this resident seated in a high-back wheelchair with regular dress socks and her left foot dangling between the two foot pedals. A LPN stated the resident attempts to stand without assistance and should be wearing non-slip socks, and the DON indicated she would need to determine the status of non-slip socks for this resident, noting recent use and discontinuation of an orthopedic boot and initiation of hospice services.
Failure to Provide Ordered High-Protein Supplement and Honor Food Dislike
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered high‑protein supplement and to honor a documented food dislike for a resident with multiple nutritional deficiencies and moderate cognitive impairment. The resident’s diagnoses include unspecified dementia with moderate cognitive impairment, vitamin D, E, and ascorbic acid deficiencies, and a disorder of teeth and supporting structures. A dietary physician order dated February 4, 2026, specifies that the resident is to receive a regular high‑protein supplement three times daily with meals at 7:30 a.m., 12:00 p.m., and 5:30 p.m. The same physician order/meal ticket also documents that the resident dislikes chicken. On observation at a lunch meal, the resident was served chicken cordon bleu as the entrée and did not receive the ordered high‑protein milkshake supplement, despite both the supplement and the chicken dislike being clearly documented on the physician order/meal ticket. The resident later stated that he does not like chicken, but ate the entrée because the ham inside made it more tolerable, and reported that he enjoys the high‑protein milkshakes but does not receive them consistently at every meal as ordered. A CNA confirmed that the resident did not receive the high‑protein milkshake and was given chicken in error, acknowledging that both the supplement and the chicken dislike were on the ticket. The Dietary Manager confirmed that chicken was listed as a dislike and that the high‑protein supplement was ordered three times daily, and acknowledged that the kitchen staff missed adding the supplement. The DON also confirmed that the physician order/dietary ticket documented the chicken dislike and the high‑protein milkshake order.
Failure to Update Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to update and implement fall interventions in the care plans for residents identified as high fall risks, and did not conduct thorough fall investigations. One resident with diagnoses including dementia, psychotic disturbance, and diabetes was documented as moderately cognitively impaired and required supervision for most activities of daily living. Despite being identified as a high fall risk, this resident experienced multiple falls, some unwitnessed, and the care plan was not consistently updated with new interventions following each incident. Staff involved in the falls were not asked to provide witness statements, and management did not systematically document or investigate the circumstances of each fall. Another resident, severely cognitively impaired with diagnoses such as encephalopathy, dementia, and repeated falls, also experienced an unwitnessed fall. The care plan for this resident included an 'alternate call light' intervention, which required staff to visualize the resident every 15 minutes. However, staff interviews revealed that these checks were not documented, and there was no way to verify that the intervention was consistently implemented. Staff could not confirm the last time the resident was visualized prior to the fall, and documentation in the medical record was found to be inaccurate regarding the timing of checks. Facility leadership confirmed that there was no policy or system in place to document 15-minute checks or to keep separate files for fall investigations. The only documentation available was in the electronic medical record, and there was no established process for collecting or reviewing witness statements from staff involved in falls. The lack of documentation and follow-through on care plan interventions and investigations contributed to the facility's failure to ensure a safe environment and adequate supervision to prevent accidents.
Unsanitary Hot Water Heaters in Resident Closets
Penalty
Summary
The facility failed to maintain sanitary conditions for hot water heaters located in resident closets, affecting six residents reviewed for physical environment. Observations revealed that several hot water heaters in resident closets had visible lime build-up, rust, and black mold on the units, surrounding floors, and walls. Residents reported that their clothes, which hung directly above or touched the water heaters, became very warm, and some expressed concerns about potential health risks due to the presence of mold and lime build-up. One resident's family member had previously reported concerns about mold and lime build-up to facility staff, but there was no documentation of this concern in the resident's electronic medical record, nor evidence that the issue was addressed. Interviews with staff, including the DON, Maintenance Director, and Custodian, confirmed awareness of the unsanitary conditions and the presence of water heaters in multiple resident closets. Staff acknowledged that some water heaters were in poor condition, with visible mold, rust, and lime build-up, and that resident clothing was in direct contact with the units. Despite these concerns being reported by residents and family members, and staff being aware of the issues, the unsanitary conditions persisted at the time of the survey.
Failure to Assess and Care Plan Use of Body Pillows and Concave Mattress as Restraints
Penalty
Summary
The facility failed to identify and assess the use of full body pillows and a concave mattress as physical restraints for a resident with cognitive impairment and a high risk for falls. Observations showed that the resident was consistently positioned in bed with full-length body pillows placed along both sides of the body, under a fitted sheet, on top of a concave mattress. Staff interviews confirmed that these interventions were used specifically to prevent the resident from getting out of bed, yet there was no documentation of a restraint assessment or inclusion of these interventions in the resident's care plan. The resident's medical record indicated a history of falls, cognitive impairment, and unsteady gait. Progress notes and post-fall documentation revealed multiple incidents where the resident exited the bed and ambulated unsupervised, despite the presence of body pillows and a concave mattress. On several occasions, the resident was found on the floor after attempting to self-transfer, and ultimately sustained a left pelvic fracture following a fall when the body pillows were in place. There was no evidence in the medical record of an assessment or reassessment for the use of these devices, even after falls occurred. Staff, including CNAs, an LPN, and the DON, acknowledged that the body pillows were intended to restrict the resident's ability to get out of bed and that no formal assessment or care plan intervention had been completed for their use. The facility's own restraint policy required an assessment prior to the use of any restraint and regular reassessment, but this was not followed. The hospice nurse practitioner also noted that the combination of body pillows and a concave mattress increased the resident's risk for injury by creating additional obstacles to safe bed exit.
Failure to Protect Residents Following Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to protect residents from further abuse by staff following an allegation of staff-to-resident abuse. Specifically, a resident reported to CNAs that a male CNA was rough while cleaning the perineal area during a shower, resulting in a 2 cm by 1 cm open area with bleeding on the scrotum. The incident was documented in nursing notes, and the resident's family and the administrator were notified. Multiple staff interviews confirmed that the resident reported the male CNA was rough, and that the injury was observed and reported to nursing staff. The CNA in question was identified as the only male CNA working on the resident's hallway during the relevant shift, and assignment records confirmed his presence on the unit with the resident and other residents. Despite the resident's report and staff observations, the administrator did not consider the incident to be an abuse allegation and did not report it to the state health department. The alleged perpetrator was not suspended pending investigation, contrary to the facility's own abuse prohibition and reporting policy, which requires immediate suspension of any employee alleged to have committed abuse. The CNA continued to work on the unit with other residents after the allegation was made, and no immediate protective measures were implemented.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent incidents of both staff-to-resident and resident-to-resident abuse, affecting two residents. In one incident, a Certified Nursing Assistant (CNA) used profanity and physically handled a resident with severe cognitive impairment and dementia by placing hands on the resident's shoulders to restrict movement in a wheelchair. A family member witnessed the CNA aggressively jerking the wheelchair and using profane language toward the resident. The CNA had a documented history of prior disciplinary actions for similar behaviors, including previous use of profanity in the presence of residents and leaving residents unsupervised. In a separate incident, a resident with a history of verbal and physical aggression entered another resident's room despite being told not to by both a CNA and the resident. The aggressive resident picked up a plastic bubble wand and struck the other resident on the head and face, resulting in a significant bump, bruising, dizziness, and a high level of pain. The CNA present was unable to immediately intervene as he was providing care to another resident at the time. Both incidents demonstrate a lack of adequate supervision and failure to enforce abuse prevention policies. The facility's own documentation and staff interviews confirm that the abuse occurred and that the affected residents suffered physical and emotional harm as a result. The facility's policies prohibit such abuse, but repeated violations and insufficient supervision contributed to the deficiencies.
Failure to Provide Safe Transfer and Supervision for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of falls and multiple diagnoses, including dementia, muscle wasting, and difficulty walking, was admitted to the facility and assessed as high risk for falls. The resident required substantial to maximal staff assistance with transfers, as documented in both the physical therapy evaluation and the certified nursing assistant task sheet. Despite these documented needs, staff failed to provide the necessary assistance, and the resident was allowed to self-transfer and self-toilet without supervision. On the day of the incident, the resident was found on the floor in his room, having attempted to go to the bathroom independently. The environment was free of clutter, and the call light was not activated. The resident reported tripping over his heel while trying to reach the bathroom, which was approximately eight feet away from where he was found. He sustained severe injuries, including fractures to the left shoulder and left hip, requiring emergency medical attention and surgical intervention. Staff interviews revealed a lack of awareness regarding the resident's need for assistance and a misunderstanding of his level of independence, despite clear documentation of his high fall risk and need for staff support. Additionally, the facility failed to implement targeted post-fall interventions to address the root cause of the resident's self-toileting behavior. The care plan did not include increased toileting assistance or supervision prior to the incident, and staff did not recognize or act upon the resident's history of impulsivity and previous falls. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive the level of supervision and assistance required to prevent accidents.
Failure to Timely Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) Resident Assessment Instruments to the Centers for Medicare and Medicaid Services (CMS) within the required time frames for five residents. Specifically, the MDSs for these residents had Assessment Reference Dates (ARDs) in February, but the submissions were not completed until late April, well beyond the regulatory deadlines. In one case, an MDS was still not completed or transmitted as of the end of April. The facility's CMS Submission Reports confirmed the late submissions, and the MDS Coordinator acknowledged the delays during an interview. The MDS Coordinator explained the required timing process, which allows 14 days after the ARD to complete the assessment, 7 days to code the MDS, and an additional 7 days to transmit the data to CMS. Despite this process, the MDSs for the affected residents were not transmitted within the required time frames, as confirmed by both documentation and staff interview. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Complete Level 2 PASRR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to obtain Level 2 Pre-admission Screening and Resident Review (PASRR) assessments for four residents who were diagnosed with severe mental illness after admission. In each case, the residents were initially admitted with no indication of mental illness or developmental disability, as documented by their original Level 1 PASRR screenings. However, subsequent diagnoses of severe mental illnesses such as Psychotic Disorder with Delusions, Bipolar Disorder, Psychosis, and Schizoaffective Disorder were made after admission. Despite these new diagnoses, there was no documentation of Level 2 PASRR assessments being completed for these residents in their comprehensive medical records. Interviews with facility staff revealed a misunderstanding of PASRR requirements, with staff believing that Level 2 PASRRs were only necessary for new admissions or in cases of significant change, rather than when a new mental illness diagnosis was made after admission. The facility's own policy required a Level 2 PASRR for residents with new mental illness diagnoses, but this was not followed. As a result, the facility did not coordinate appropriate assessments or referrals for services as required for residents with newly identified severe mental illnesses.
Failure to Prevent Cross-Contamination During Catheter and Incontinence Care
Penalty
Summary
Staff failed to provide appropriate catheter and incontinence care for multiple residents, resulting in cross-contamination and improper infection control practices. One resident with an indwelling urinary catheter for obstructive uropathy was observed with cloudy, sediment-laden urine and a soiled catheter insertion site. During catheter care, a CNA cleaned the resident's penis in the wrong direction, causing cross-contamination at the catheter insertion site, and failed to adequately clean the soiled catheter. The DON confirmed the improper technique and acknowledged the cross-contamination. Another resident, dependent on staff for all activities of daily living and with a diagnosis of neuromuscular dysfunction of the bladder, received perineal and catheter care from two CNAs. One CNA did not change gloves or perform hand hygiene after cleaning the front perineal area before moving to the rear, and a contaminated drainage bag cover was placed back over the urinary drainage bag after falling to the floor. Barrier cream was not applied after perineal care, contrary to facility policy. The DON confirmed that gloves should have been changed, hand hygiene performed, and a new drainage bag cover used. A third resident, severely cognitively impaired and dependent on staff, was provided incontinence care by two CNAs. After cleansing urine and feces from the resident's buttocks, a clean incontinence brief was applied without changing gloves or performing hand hygiene. The CNA later acknowledged the lapse, and the DON confirmed that hand hygiene should have been performed after incontinence care and before applying a new brief.
Resident Dignity Compromised During Shower Transfer
Penalty
Summary
A resident with diagnoses including Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and severe cognitive impairment was observed being transported by two CNAs from his room to the shower room while reclined in a mesh slatted shower chair. The resident was only covered by a thin bath blanket, leaving his left shoulder, trunk, buttock, and thigh visible. During this transfer, the resident was pushed past the nurse's station where other residents and staff were present, resulting in exposure. Interviews revealed that staff routinely undressed the resident in his room before transporting him to the shower room, citing the difficulty of transferring him once inside the shower room. The resident's Power of Attorney stated that the resident, a former minister with a history of modesty, would not have appreciated being unclothed in public. The facility's administrator confirmed that residents should be appropriately covered during transfers and that the shower room could accommodate necessary equipment for dressing or undressing. Facility policy requires residents to be treated with dignity and respect, which was not upheld in this instance.
Failure to Complete Required Level 2 PASRR for Resident with Intellectual Disability
Penalty
Summary
The facility failed to obtain a required Level 2 Pre-admission Screening and Resident Review (PASRR) for one resident who was diagnosed with Major Depressive Disorder with recurrent psychotic symptoms and documented as having an Intellectual Disorder. The resident's face sheet confirmed the diagnosis, and the Level 1 PASRR indicated the presence of an Intellectual Disorder. However, there was no documentation that a Level 2 PASRR had been completed for this resident. The administrator stated that the facility had only been completing Level 2 PASRRs when there was a significant change in status and was not aware that a Level 2 PASRR was required for all residents with an Intellectual Disability, as outlined in the facility's own policy.
Incomplete Oxygen Order and Unlicensed Administration
Penalty
Summary
A deficiency occurred when the facility failed to transcribe the complete physician order for oxygen administration for a resident with diagnoses including pneumonia, emphysema, and a stage II sacral pressure ulcer. The physician order sheet for the resident documented oxygen therapy but left the prescribed liter flow rate blank. During an observation, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was not turned on. The resident reported not receiving oxygen, prompting a certified nursing assistant (CNA) to turn on the concentrator and set the flow rate to two liters per minute. A registered nurse (RN) verbally confirmed the rate from across the bed after the CNA had already set it. The facility's policy requires that only licensed nurses administer oxygen and that physician orders specify details such as when to use, how often, the liter flow, and the delivery method. The administrator confirmed that the order should have included the oxygen rate and that only licensed nurses are permitted to administer oxygen, in accordance with facility policy and standard practice. The failure to transcribe the complete order and to ensure a licensed nurse administered the oxygen led to the deficiency.
Failure to Maintain Call Light Accessibility Resulting in Delayed Pain Management
Penalty
Summary
A deficiency occurred when a resident with a history of pain, osteoporosis, difficulty walking, and muscle atrophy was unable to access her call light and bedside table during the night. The resident, who was cognitively intact, reported that she experienced severe leg pain while in bed and was unable to summon assistance because the call light was out of reach. She attempted to call out for help, but her voice was too soft to be heard, and she did not have a roommate to assist her. As a result, she remained in pain for several hours until the morning, when she reported the incident to a nurse. Documentation showed that the resident had a PRN order for Tramadol for pain, but the nurse who administered the medication in the morning did not document the resident's pain level as required by facility policy. Interviews with staff confirmed that the call light and bedside table were out of reach during the night, and that this information was communicated among staff members. Facility policies required that call lights be accessible at all times and that pain assessments be documented every shift, but these procedures were not followed in this instance.
Failure to Provide Behavioral Health Services and Training Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide necessary behavioral health care and services, as well as behavioral health services training, for a resident with significant behavioral health needs. The resident, who was diagnosed with Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and violent behavior, was severely cognitively impaired and dependent on staff for all activities of daily living. Despite documented care plan interventions instructing staff to ensure safety and re-approach the resident with different staff when physical behaviors occurred, the resident experienced multiple incidents of combative behavior during care, resulting in several skin tears and minor injuries. These injuries occurred during routine care activities such as bedtime care, transfers, and shower preparation, with staff sometimes failing to follow recommended interventions such as walking away or seeking assistance. Additionally, the facility did not have psychiatric services available until after several of these incidents had occurred, and the resident had not yet been seen by the psychiatric nurse practitioner. Staff had not received training on behavioral health or on providing care for residents with behavioral issues. Furthermore, required follow-up procedures were not consistently followed, as some injuries were not reported or investigated according to facility policy, resulting in missed opportunities for skin evaluations and appropriate notifications. The facility's policy on PASRR was not fully implemented, as recommendations from Level 2 screens and significant changes in status were not consistently incorporated into the care plan.
Failure to Ensure Respect and Dignity for Residents
Penalty
Summary
The facility failed to ensure the right of being treated with respect and dignity for two residents, R1 and R2, as part of an abuse investigation. For R2, the investigation revealed that a Certified Nurse's Assistant (CNA), V4, allegedly made inappropriate comments suggesting that no one liked R2 and that no one wanted to answer R2's call light. Although the abuse was deemed unsubstantiated due to R2's hearing difficulties, R2 reported feeling rushed and uncomfortable with V4's demeanor, describing V4 as unwilling to engage and perform care tasks willingly. The Director of Nursing (DON) acknowledged the issue and had previously educated V4 on communication and care delivery. In the case of R1, the investigation documented that V4 was reported to have entered R1's room frequently, causing discomfort and anxiety. R1 described V4 as having a rude and abrupt manner, making R1 feel disrespected and as if R1 was on V4's time. The Social Service Director and the DON were informed of these concerns, and it was noted that this was the second complaint regarding V4's verbal interactions with residents. Despite the abuse being unsubstantiated, the facility recognized V4's inappropriate communication style, leading to the decision to terminate V4's employment.
Resident Falls from Shower Chair, Sustains Multiple Fractures
Penalty
Summary
The facility failed to safely transport a resident after a shower, resulting in a traumatic fall. The resident, who has a medical history of Spastic Paraplegia, Abnormal Posture, Difficulty in Walking, and Muscle Wasting and Atrophy, is completely dependent on staff for all activities of daily living and uses a wheelchair for mobility. On the day of the incident, a Certified Nurse Aide was moving the resident on a shower chair when a wheel became caught on the shower curb, causing the resident to fall to the ground. This fall resulted in multiple back and neck fractures, requiring emergency medical evaluation and treatment at two hospitals. The resident was diagnosed with six fractures in the thoracic, lumbar, and cervical vertebrae and received intravenous morphine for severe pain at a regional trauma center. The resident remained an inpatient at the trauma center for several days before returning to the facility with orders for analgesic pain medication and a rigid cervical immobilizer. Prior to the fall, the resident had only taken a single dose of acetaminophen for pain in September, but after returning to the facility, the resident required pain medication nearly every day.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager, which has the potential to affect all 80 residents residing in the facility. During the survey conducted from June 4 to June 7, 2024, no Certified Dietary Manager was observed in the dietary department. On June 4, 2024, a dietary aide mentioned that the facility had not had a dietary manager for almost a year. The facility administrator confirmed on June 5, 2024, that the position had been vacant for six months, although an offer had been made to a prospective candidate. The administrator also stated that the Registered Dietician is onsite monthly and reviews resident charts remotely every week, but is not present full-time. The facility does not have a policy mandating a Certified Dietary Manager, but it is acknowledged that one is supposed to be employed.
Unsanitary Kitchen Conditions and Expired Food in LTC Facility
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illnesses affecting all 80 residents. During a kitchen tour, several deficiencies were observed, including a commercial ice machine with rust buildup, a rust-covered metal shelf under a leaking coffee maker, and standing water under a juice dispenser with rusted shelves. Additionally, expired food items were found in storage, such as lime juice and instant cheese mix, which were not disposed of in a timely manner. The facility also lacked a cleaning schedule for kitchen equipment, leading to significant grease and charcoal-like buildup on grills, stoves, and ovens. Further observations revealed a rusted and malfunctioning commercial can opener, and a dishwashing station with cracked and chipped caulking. These issues were confirmed by the facility's staff, who acknowledged the need for maintenance and cleaning. The facility's policy on cleaning and sanitizing work surfaces and equipment was not adequately followed, contributing to the unsanitary conditions. The report highlights the facility's failure to adhere to professional standards for food storage, preparation, and equipment maintenance, posing a risk to resident health and safety.
Failure to Maintain Resident Dignity in Toileting and Meal Assistance
Penalty
Summary
The facility failed to honor residents' right to dignity by not providing timely toileting assistance and engaging in inappropriate staff behavior during meal service. A resident, identified as R62, reported having to wait for long periods for staff assistance with toileting, resulting in episodes of incontinence and feelings of humiliation. Despite being continent of bowel and bladder, R62 required assistance from two staff members for transfers and ambulation due to decreased strength. The facility's policy on call light response was not adhered to, as the resident's call light was not answered promptly, leading to the resident being left in soiled conditions. Additionally, during meal service, staff members were observed engaging in personal conversations unrelated to resident care while providing feeding assistance to residents with severe cognitive impairments. Staff, including an MDS Coordinator and CNAs, were noted to be talking amongst themselves about off-work activities, rather than interacting with the residents they were assisting. This behavior was observed across multiple tables in the dining room, with minimal communication directed towards the residents, who were given only short instructions related to eating. The facility's failure to engage with residents during meal times and the delay in responding to toileting needs were acknowledged by the facility's Administrator/Registered Nurse as dignity issues. The facility's Residents' Rights Pamphlet emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances. The report highlights the need for staff to focus on resident interaction and timely response to care needs to maintain the dignity and quality of life of the residents.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a clean and sanitary manner, affecting four residents who required respiratory or oxygen therapy. The facility's policy mandates that oxygen equipment, such as cannulas, masks, and tubing, should be exchanged every seven days and stored off the floor in a sanitary manner. However, observations revealed that the equipment was not dated when changed and was improperly stored. For instance, one resident's oxygen tubing was found laid over the bed and bed frame without a bag for sanitary storage, while another resident's tubing was on the floor and bed without proper storage. Additionally, a resident's oxygen humidifier bottle was found sitting on a dirty floor, and the nebulizer face mask of another resident was dated several months prior and placed on top of a dirty sock without being stored in a bag. These observations were confirmed by the facility's staff, including a nurse manager and an infection preventionist, who acknowledged that the equipment should be stored in a more hygienic manner and dated appropriately. The failure to adhere to these standards compromised the sanitary conditions required for respiratory care.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to prevent cross-contamination during meal service by not adhering to proper hand hygiene protocols. This deficiency was observed in multiple instances involving five residents. For instance, a Certified Nurse Aide (CNA) used her bare hands to move food on a resident's plate without using gloves or performing hand hygiene. This resident had a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) and other medical conditions, making infection control crucial. Additionally, a Licensed Practical Nurse (LPN) assisted two residents with eating without using hand hygiene or alcohol-based hand rub (ABHR) between assisting each resident. This included an incident where a piece of food fell onto the LPN's wrist, and the LPN continued to assist another resident without cleaning her hands. Another CNA was observed assisting two residents with their meals, using her hands to reposition herself and then handling a resident's drinking cup without performing hand hygiene. The facility's policy on hand washing, which emphasizes the importance of hand hygiene in preventing the spread of infections, was not followed. These actions demonstrate a failure to adhere to infection prevention protocols, potentially exposing residents to cross-contamination and infection risks.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of verbal and physical abuse of a resident by a staff member to the Abuse Coordinator. This deficiency involved a resident with medical diagnoses including Postural Kyphosis, Hypertension, Anxiety Disorder, Altered Mental Status, Dysuria, Overactive Bladder, Open Angle Glaucoma, Corneal Edema, and Macular Degeneration. The resident's Power of Attorney alleged that a Certified Nurse Aide was rough during care, yelled at the resident, and left them in wet clothes after a shower. The facility's Administrator was unaware of the incident until a later date, indicating a failure in the reporting process. The Director of Nurses confirmed that the aide received a written warning and was suspended during the investigation, which overlapped with the aide's vacation time. The facility's policy requires immediate reporting of alleged abuse or neglect to the Administrator or Director of Nurses, which was not followed in this case.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with Enterocolitis due to Clostridium Difficile. The resident's care plan required the administration of antibiotics as ordered, specifically Fidaxomicin 200 mg twice daily for ten days. However, the Medication Administration Record (MAR) revealed that the antibiotic was not administered on several occasions, including the PM dose on the day of discharge, and doses on subsequent days. A registered nurse confirmed these omissions, acknowledging that the medication was not given as prescribed. The facility's Medication Administration Policy mandates that medications deemed necessary by the physician should be provided to stabilize the resident's condition.
Failure in Infection Control During Catheter Care
Penalty
Summary
The facility failed to prevent cross-contamination during urinary catheter care for a resident identified as R55. R55 has multiple medical diagnoses, including Parkinson's Disease, Malignant Neoplasm of Prostate, and Bladder-Neck Obstruction, and is dependent on staff for personal hygiene and toileting. On a specific date, a Certified Nurse Aide (CNA), identified as V11, provided urinary catheter care to R55 without changing gloves or performing hand hygiene after the gloves were contaminated with stool. The CNA continued to use the contaminated gloves to clean the urinary catheter tubing, which is a breach of proper infection control practices. The CNA acknowledged the mistake, stating that gloves should have been changed after providing bowel incontinence care and before performing catheter care. The Infection Preventionist (IP), identified as V9, emphasized the importance of hand hygiene in reducing infection risks and confirmed that staff should change gloves when they become contaminated. This incident highlights a failure in adhering to infection control protocols, potentially increasing the risk of infection for the resident.
Failure to Conduct Psychotropic Medication Assessments
Penalty
Summary
The facility failed to complete necessary Psychotropic Medication Assessments for two residents, leading to a deficiency in managing unnecessary medications. One resident, diagnosed with Dementia with Behavioral Disturbances and Depression, was prescribed Citalopram and Olanzapine but had not undergone a Psychopathological Observation in the past year. Another resident, diagnosed with Depression and Generalized Anxiety, was prescribed Buspar and Citalopram but did not receive an Initial Psychopathological Observation upon admission, despite being on these medications. These assessments are crucial for creating a data base for the Care Plan and Gradual Dose Reduction Program, as outlined in the facility's Psychopharmacological Drug Usage Procedure.
Failure to Serve Meals at Palatable Temperature
Penalty
Summary
The facility failed to provide meals at a palatable temperature for two residents, R51 and R52, as observed during a survey. Both residents were on a regular consistency diet as per their Physician Order Sheets. On the day of observation, R51 reported that her food was cold by the time it reached her room, and she only consumed about 10% of her lunch. Similarly, R52 also complained about the cold temperature of her meal, consuming only 25% of it. Both residents expressed dissatisfaction with the cold gravy on their beef cutlet. The deficiency was further highlighted by the actions of staff member V24, who delivered meals to both residents without covering the trays, which likely contributed to the meals being served cold. V24 acknowledged that covering trays could be beneficial, as there were frequent complaints about cold food. The Nurse Manager, V3, confirmed that meal trays should be covered during delivery to maintain temperature, although there was no formal policy in place. This lack of action in covering the food trays led to the residents receiving meals that were not at an appetizing temperature.
Failure to Provide Modified Diet as Ordered
Penalty
Summary
The facility failed to serve a modified diet as ordered for a resident with severe cognitive impairment. The resident's physician order specified a liquidized diet with nectar thick liquids. However, during a meal observation, a Certified Nursing Assistant (CNA) fed the resident pureed food thickened to a nectar consistency and a watered-down tomato soup that was not thickened as required. The resident began coughing immediately and repeatedly after consuming the un-thickened soup. A Licensed Practical Nurse (LPN) present at the scene instructed the CNA to pause feeding. The CNA acknowledged that the tomato soup was too thin and that the kitchen was responsible for thickening the resident's drinks. A cook later admitted to missing the step of thickening the soup while training another cook, despite knowing it was necessary.
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Illustrative
What surveyors actually found near you
We read the 152 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 Healthcare & Senior Living | 0.8 mi | ★★★★★ | 1 | 1 |
| Pana Health And Rehab Center | 15.2 mi | ★★★★★ | 1 | 0 |
| Sullivan Healthcare & Senior Living | 15.3 mi | ★★★★★ | 22 | 0 |
| Rose Garden Of Pana | 15.6 mi | ★★★★★ | 11 | 0 |
| Eastview Healthcare & Senior Living | 16.7 mi | ★★★★★ | 9 | 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 July 2026) and official state health department websites.