Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Especially Kidz Health & Rehab during CMS and state inspections, most recent first.
Failure to Clarify Midodrine BP Parameters: A resident with ventricular tachycardia and HTN had a physician order for midodrine 5 mg q8h to be held for BP >120, but nursing staff both administered and held the medication based on systolic BP readings without timely clarifying the order. The DON stated the order should have been clarified with the physician, and the facility policy required staff to clarify any questions with the charge nurse or provider.
Infection control was not maintained during two observed care events. An LPN performed wound care for a resident on EBP without wearing the required gown, despite the room sign indicating gown and gloves were needed for wound care. In a separate medication pass, an LPN touched pill medications with bare hands while preparing meds for a resident, even though the DON stated staff should not touch medications with hands and the facility policy said never to touch medications with hands.
An LPN failed to administer physician-ordered medications to three residents with complex medical needs, including ventilator dependency and NPO status, and falsified documentation to indicate the medications were given. Camera footage and staff observations confirmed the LPN removed narcotics from the cart, handled them improperly, and did not deliver them to the residents, instead discarding or pocketing the medications and signing records as if they had been administered.
Surveyors found that several unopened food items in the freezer, such as tater tots, mixed vegetables, and pork patties, were not properly closed or secured, contrary to facility policy requiring frozen items to be sealed to prevent air exposure and frost damage. The Dietary Supervisor confirmed these items should have been stored to prevent air contact.
Staff failed to perform required hand hygiene before donning gloves and administering medications, including via g-tube, for multiple residents. Staff were observed touching various surfaces and equipment with gloved hands and then handling medications and administering them without proper hand hygiene, contrary to facility policy.
Multiple rooms were found with broken blinds, a dusty and uncovered box fan, and a dusty fall mat, indicating a failure to maintain a clean, safe, and homelike environment for several residents. Facility staff were unaware of some of these issues, and there was no specific policy in place regarding the homelike environment.
The facility did not provide necessary assistance with ADLs for a resident who remained in bed despite being able and ready to get up, and failed to ensure two residents received adequate oral care, including the use of lip balm as ordered. Staff did not follow care plans or physician orders, resulting in unmet care needs for these dependent residents.
A resident with traumatic brain injury and quadriplegia was not provided with activities such as music or TV as outlined in their care plan, despite being observed awake and responsive to music. Staff were unable to provide these activities due to missing equipment, and the care plan did not reflect any preference for quiet time, resulting in unmet activity needs.
A resident with significant physical impairments was repeatedly observed in their wheelchair without the required headrest, as specified in their care plan. The absence of the headrest led to improper head positioning, with the resident's head lolling backward and jerking forward. Staff interviews indicated the headrest was missing and there was no policy in place to ensure adaptive equipment was consistently used.
Failure to Clarify Midodrine Blood Pressure Parameters
Penalty
Summary
The facility failed to timely clarify the vital sign parameters of a physician’s order for Resident 50. The resident’s clinical record showed diagnoses including ventricular tachycardia and hypertension. On 2/18/26, the physician ordered midodrine 5 mg every 8 hours, to be held for blood pressure greater than 120. The care plan, last reviewed 5/13/26, identified hypertension and risk for associated complications, with a goal of no signs or symptoms of hypertension and an intervention to administer medications as ordered by the physician. The April and May 2026 MAR showed that nursing staff administered midodrine when the resident’s systolic blood pressure was above 120 on several occasions, including readings of 123/69, 125/57, 146/76, and 122/70. The MAR also showed the medication was held on other occasions because systolic blood pressure was above 120. During interview, the DON stated the nursing staff should have clarified the midodrine order with the physician. The facility’s Medication Administration Policy stated that orders should be read carefully and any questions clarified with the charge nurse or physician/provider.
Infection Control Lapses During Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain infection control during wound care for a resident on Enhanced Barrier Precautions. The resident’s record showed an EBP sign at the room entrance indicating gown and gloves were required for high-contact care activities, including wound care. During an observed dressing change on the back of the resident’s head, the ADON wore a gown and gloves, but the LPN performing the wound care wore gloves only and did not don a gown. The LPN removed the old dressing, cleaned the wound, and applied a new dressing without the required gown, and later stated she had forgotten to put one on and acknowledged that a gown was required during the wound care. The facility also failed to maintain infection control during medication administration for another resident with cerebral palsy. During an observed medication pass, an LPN handled the medication cart, medication cards, computer mouse, and pill medications, then used bare hands to remove two pills from a medication cup because they could not be crushed. She crushed the remaining pills, returned them to the cup, added the two uncrushed pills and applesauce, and administered the medications to the resident. The DON stated nursing staff should not touch pill medications with their bare hands. The facility’s EBP policy stated gown and gloves are required during high-contact resident care activities, and the medication administration policy stated to never touch medications with hands.
Failure to Administer Medications and Falsification of Records by LPN
Penalty
Summary
A staff member, specifically an LPN, failed to administer medications as ordered by physicians to at least three residents during a scheduled medication pass. The incident was discovered after other staff members raised concerns that the LPN had not been observed providing medication assistance during the assigned shift. Subsequent review of facility camera footage revealed that the LPN removed narcotic medications from the medication cart, handled them with bare hands, and either discarded or pocketed the medications instead of administering them to the residents. The LPN was also observed documenting in the narcotic binder and medication administration records (MAR) that the medications had been given, despite evidence to the contrary. The residents involved were all on ventilator support, had tracheostomies, and were dependent on gastrostomy tubes for medication administration due to NPO (nothing by mouth) status. Each resident had physician orders for diazepam to be administered via gastrostomy tube at specific times. The MARs and narcotic records indicated that the medications were signed out as administered by the LPN, but camera footage and staff observations confirmed that the medications were not actually given. The LPN did not follow proper medication administration procedures, including the use of medication cups and pill crushers, and failed to enter resident rooms to deliver the medications after removing them from the cart. The facility's investigation confirmed that the LPN falsified records by signing out medications that were not administered and did not adhere to infection control protocols, such as avoiding direct hand contact with medications. The incident was reported to the facility's executive leadership, and the LPN was suspended and subsequently terminated following the investigation. The facility did not file a reportable incident with the state health department, as there were no observed adverse effects to the residents involved.
Improper Storage of Unopened Frozen Food Items
Penalty
Summary
During a kitchen inspection with the Dietary Supervisor, surveyors observed that several unopened food items in the walk-in freezer, including a box of tater tots, two boxes of mixed vegetables, and a box of pork patties, were not properly closed or secured. The Dietary Supervisor confirmed that these items should have been stored in a manner that prevents air from reaching the product. Facility policy requires that frozen items not individually wrapped be placed in storage bags or tightly wrapped in plastic wrap before being returned to their original boxes, and that all open boxes in the freezer must be resealed to prevent frost damage. The observed failure to properly seal these food items was not in accordance with the facility's storage guidelines and procedures for frozen food safety.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for four out of five residents observed. Specifically, staff members, including LPNs and QMAs, did not perform hand hygiene at critical points, such as before donning gloves and gowns or before administering medications, including those given via gastrostomy tube (g-tube). Staff were observed touching various surfaces and equipment, such as medication carts, computer mice, narcotic boxes, and medication cards, with gloved hands, and then proceeding to handle medications and administer them to residents without performing hand hygiene in between these steps. The residents involved included individuals receiving medications both orally and via g-tube, with staff preparing and administering medications without following established hand hygiene protocols. The facility's own policies required hand hygiene before and after direct resident contact, before and after entering isolation settings, after removing gloves, and specifically before and after administering medications, including those given through feeding tubes. Despite these policies, observations revealed repeated lapses in hand hygiene, as confirmed by interviews with facility leadership.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for four out of five residents reviewed. Observations revealed that multiple resident rooms had broken blinds with missing pieces, resulting in gaps even when the blinds were closed. In one resident's room, a box fan was found to be dusty and missing a cover on one side, exposing the fan blade. Another room contained a fall mat folded up between the bed and the wall, which was also covered in dust. These conditions were observed on multiple occasions, indicating that the issues were not promptly addressed. During an environmental tour with the Housekeeping Supervisor and Maintenance Director, the same deficiencies were noted, including the broken blinds, dusty fan with missing cover, and dusty fall mat. The Maintenance Director, who was new to the position, was not aware of the specific needs for replacement blinds, and the Housekeeping Supervisor was unaware of the presence of the box fan. The Housekeeping Supervisor stated that dusting items in residents' rooms was part of daily cleaning. The Nurse Consultant confirmed there was no specific policy regarding a homelike environment, but that the facility followed regulations related to it.
Failure to Assist with ADLs and Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who were unable to perform these tasks independently. One resident with multiple significant diagnoses, including cerebral palsy, profound intellectual disabilities, epilepsy, and a stage 4 pressure ulcer, was observed lying in bed on multiple occasions and had not been assisted out of bed, despite being ready and able to do so. Staff indicated that the resident was not to be transferred out of bed due to a recent sacral wound repair, but there was no physician order requiring the resident to remain in bed, and the care plan called for assistance with ADLs, including transfers. Additionally, two other residents with cerebral palsy and profound intellectual disabilities were not provided adequate oral care as required by their care plans and physician orders. Both residents were observed with dry, cracked lips on multiple occasions, and neither had lip balm available in their rooms as specified in their care plans. Staff confirmed that oral care, including the application of lip balm, was to be completed every shift, but this was not done until after the deficiency was identified. The facility's policies required comprehensive, person-centered care plans to be developed and implemented for each resident, including measurable objectives to meet their medical, nursing, and psychosocial needs. The failure to assist residents with transfers and oral care as outlined in their care plans and physician orders resulted in unmet care needs for these residents.
Failure to Provide Planned Activities for Resident with Cognitive and Sensory Needs
Penalty
Summary
A deficiency was identified when a resident with a history of traumatic brain injury and quadriplegia was not provided with activities as outlined in their care plan. The care plan specified that the resident may benefit from cognitive, social, and sensory stimulation, including music, sensory activities, stories, TV, and massage, with TV or music to be on in the room while awake as tolerated. Multiple observations over several days found the resident awake in bed or in a chair with neither the television nor music playing. Staff interviews confirmed that the resident enjoyed music, particularly rap, and responded positively when it was mentioned, but the necessary equipment (remote control) to provide these activities was not available in the room at the time of observation. The resident's representative indicated that the resident enjoyed music and was also fine with quiet time, but the care plan did not document a preference for quiet time. Facility policy requires that activities be provided based on the comprehensive assessment and care plan, supporting residents' interests and well-being. Despite this, the resident was not consistently provided with the planned activities, and there was no documentation or observation of alternative activities being offered during the survey period.
Failure to Provide Required Headrest for Resident's Wheelchair
Penalty
Summary
A resident with spastic quadriplegic cerebral palsy, neuromuscular scoliosis, and epilepsy was observed multiple times without a headrest attached to their adaptive wheelchair, despite care plans specifying the need for a standard or heads-up headrest to maintain proper body positioning and alignment. The resident was seen sitting in the wheelchair with no headrest, resulting in their head repeatedly lolling backward and jerking forward as they fell asleep. The clinical record and care plans confirmed the resident's significant impairments in both upper and lower extremities, necessitating the use of adaptive equipment for positioning. Staff interviews revealed that the headrest, which was standard equipment for the wheelchair, was missing and may have been removed for cleaning and not replaced. The physical therapist confirmed that a headrest should have been present and later found it stored in the resident's closet. At the time of the deficiency, there was no facility policy in place regarding adaptive equipment, contributing to the oversight and lack of consistent use of required positioning supports for the resident.
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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) |
|---|---|---|---|---|
| Willows Of Shelbyville | 0 mi | ★★★★★ | 16 | 0 |
| Ashford Place Health Campus | 3.8 mi | ★★★★★ | 0 | 0 |
| Waldron Rehabilitation And Healthcare Center | 7.1 mi | ★★★★★ | 7 | 0 |
| Morristown Manor | 12.1 mi | ★★★★★ | 0 | 0 |
| Homeview Center Of Franklin | 13.9 mi | ★★★★★ | 3 | 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.