Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Willows Of Shelbyville during CMS and state inspections, most recent first.
Three residents with cognitive and physical impairments did not have their fall prevention interventions in place as specified in their care plans. One was observed without required non-skid footwear, another lacked non-skid strips in front of her chair, and a third was missing a pommel cushion in her wheelchair, with staff either unaware of the intervention or unable to provide it.
A resident with multiple health conditions and significant weight loss did not receive a physician-ordered nutritional supplement at lunch, and her family was not consistently given the opportunity to complete weekly menus as care planned. The resident was served foods she did not like, and the dietary staff failed to ensure the supplement was provided, despite clear instructions on the meal ticket.
A resident with dementia and a history of skin picking was observed with untreated facial wounds, but her care plan was not updated to address this behavior, and staff failed to document or monitor the issue as required by facility policy.
Three residents with indwelling urological devices were observed multiple times with their drainage bags and tubing in direct contact with the floor, contrary to care plans and infection control protocols. Despite orders for daily care and enhanced barrier precautions, staff did not prevent the devices from touching the floor, as confirmed by observations and interviews with the Infection Prevention Nurse.
The facility failed to maintain kitchen equipment cleanliness and proper sanitization levels, affecting all residents. The Dietary Manager lacked test strips to verify sanitization bucket chemical levels due to expired strips and supplier backorder. Additionally, a brown fuzzy substance was found on refrigerator racks, which remained uncleaned despite available supplies. Facility policies did not adequately address these issues.
The facility failed to properly store food and maintain hygiene in the kitchen, affecting all residents. Observations included improperly stored silverware, inadequately sealed food packages, and open syrup bottles. A staff member was seen without a beard cover while serving food. The kitchen environment was unclean, with cobwebs, debris, and dead insects in light fixtures, indicating a failure to adhere to cleanliness standards.
The facility failed to maintain the kitchen in a clean and well-repaired state, affecting all residents. Observations included missing baseboards, cracked wall covers, and missing tiles in various areas. The dry storage room had significant dirt and debris, and the walk-in cooler had spills and possible rust. Weekly cleaning logs showed several areas were not signed off as cleaned, and logs for early August were missing. The facility's cleaning policy was not followed.
The facility failed to redirect residents with dementia who wandered into others' rooms, compromising privacy. Despite care plans for managing wandering behaviors, staff did not consistently intervene, and there were no structured activities to engage residents. Interviews revealed a lack of regular activity staff and inadequate supervision, leading to repeated incidents of uninvited room entries.
A facility failed to accurately document a resident's code status, resulting in a discrepancy between the POST form and physician orders. The resident's POST form indicated CPR was to be administered, while the physician's orders stated otherwise. Interviews revealed procedural gaps, including a lack of proper explanation to the resident and failure to maintain an updated binder of code statuses.
The facility failed to accurately encode MDS assessments for two residents, leading to documentation errors. One resident's MDS inaccurately indicated no hospice services despite continuous hospice care, while another's MDS incorrectly noted anticoagulant use without corresponding physician orders. The MDS Coordinator confirmed these errors.
A facility failed to conduct timely care plan meetings for a resident with Parkinson's disease, COPD, and major depressive disorder. The resident, who was cognitively intact, did not recall having care plan meetings, and records showed a gap between meetings from December to July. The Social Service Director could not find records of these meetings, despite being responsible for scheduling them quarterly and as needed, as per the facility's policy.
A resident with a history of falls experienced an unwitnessed fall, resulting in incomplete neurological checks by the facility. Despite the policy requiring frequent assessments, documentation showed gaps, and the resident was later sent to the hospital unresponsive.
The facility failed to implement and evaluate a resident's behavioral health care plan, leading to multiple incidents of physical aggression towards staff and other residents. The care plans were outdated, and there was inadequate documentation and follow-up on the aggressive behaviors. Additionally, the facility did not report these incidents to the Indiana Department of Health.
The facility failed to ensure a resident with dementia had a care plan with specific interventions for inappropriate behaviors, leading to repeated incidents of inappropriate touching of other residents. Despite being on medication and having a history of such behaviors, the resident's actions were not adequately monitored or documented, compromising the safety of other residents.
The facility failed to ensure narcotic medication was administered per physician orders for two residents. One resident with Huntington's disease had multiple instances of undocumented diazepam administration, while another resident reported issues with receiving scheduled pain medication, with several instances of undocumented Norco administration.
Failure to Implement Fall Prevention Interventions per Care Plans
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for three residents. One resident with osteoporosis, Alzheimer's disease, and chronic pain had a history of unwitnessed falls, including one resulting in a hip fracture. Despite a care plan intervention requiring appropriate footwear, the resident was observed wearing regular socks without non-skid features or shoes while in the dining room. Staff confirmed the absence of non-skid socks and acknowledged the resident should have been wearing tennis shoes. Another resident with Alzheimer's disease and multiple psychiatric diagnoses had a care plan intervention for non-skid strips to be placed both beside her bed and in front of her chair. Observation revealed that while strips were present beside the bed, they were missing in front of the recliner, and the weekend supervisor was unaware of this requirement. A third resident with dementia and heart failure, who required substantial assistance with transfers and had a recent fall with injury, had a care plan intervention for a pommel cushion to prevent leaning and potential falls. Observations showed the resident was seated in a wheelchair without the pommel cushion, and staff were either unaware of what the cushion was or stated it was unavailable due to being soiled. The DON later indicated that hospice was responsible for providing the cushion, but it had not been supplied, and an alternative cushion was used without proper documentation in the care plan. These findings demonstrate that the facility did not ensure fall prevention interventions were consistently in place as specified in residents' care plans.
Failure to Provide Ordered Nutritional Supplement and Honor Resident Menu Preferences
Penalty
Summary
A resident with diagnoses including dysphagia, dementia, depression, malnutrition, and anxiety experienced a significant weight loss of 16 pounds over 180 days. The resident was on hospice services, required total assistance with feeding, and had a physician's order for a regular diet with thin consistency, finger foods as needed, and a magic cup nutritional supplement at lunch. During a lunch observation, the resident did not receive the ordered magic cup, and the CNA assisting her did not notice its absence. The meal ticket clearly indicated the need for the supplement, but the kitchen did not send it, and the dietary aide responsible for reading the ticket and placing supplements on trays did not ensure it was provided. Additionally, the resident's care plan included having a family member complete weekly menus to honor her food preferences and intolerances. However, the family member reported that he had not been given the opportunity to fill out menus recently, resulting in the resident being served items she did not like or would not eat. The Dietary Manager confirmed that menu packets were not consistently provided to the family member as agreed, missing at least three times, including the current week. The facility's policy required providing nutritional and dietary supplements consistent with assessed needs, but this was not followed for the resident.
Failure to Revise Care Plan and Monitor Self-Injurious Behavior in Dementia Resident
Penalty
Summary
The facility failed to revise the care plan and adequately monitor a resident diagnosed with dementia who exhibited skin picking and scratching behaviors. The resident, who had diagnoses including Alzheimer's disease, chronic pain, depression, and dementia, was observed with quarter-sized, reddish areas with partially scabbed centers on both cheeks. Despite these visible injuries, there were no progress notes, assessments, or care plans referencing the areas on her cheeks or her picking/scratching behavior. Staff interviews revealed that the behavior had been noticed previously, but it was not documented or addressed in the resident's care plan. The Memory Care Facilitator, responsible for care planning, acknowledged that the resident's skin picking should have been included in her care plan. The DON and other staff confirmed that the behavior was observed but not documented, and the areas on the resident's cheeks were not assessed or treated as needed. Review of the facility's behavior monitoring reports and progress notes showed no documentation of the resident's self-injurious behaviors, despite staff being aware of the issue. The facility's policy required care planning and intervention for problematic behaviors, but this was not followed for the resident in question.
Failure to Maintain Infection Control for Indwelling Urological Devices
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for residents with indwelling urological devices. For three residents with urostomies or indwelling urinary catheters, observations revealed that their drainage bags and tubing were in direct contact with the floor on multiple occasions. Specifically, one resident with a urostomy was observed twice with the drainage bag and tubing touching the floor, despite care plans and physician orders indicating the need for daily urostomy care and enhanced barrier precautions. Another resident with a suprapubic urinary catheter was seen in a wheelchair with the catheter bag contacting the floor during two separate observations, even though the care plan required catheter care every shift and enhanced barrier precautions. A third resident with an indwelling urinary catheter was observed in the dining room with the catheter bag directly on the floor, despite similar care plan interventions for infection prevention. Record reviews confirmed that all three residents had diagnoses requiring indwelling urological devices and were dependent on staff for various activities of daily living. Interviews with the Infection Prevention Nurse confirmed that staff were expected to keep catheter drainage bags and tubing off the floor to promote infection control. The repeated failure to prevent these devices from contacting the floor constituted a breach of established infection control measures as outlined in the residents' care plans and facility protocols.
Deficiency in Kitchen Sanitization and Equipment Maintenance
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean manner and ensure proper sanitization levels in sanitizing buckets, potentially affecting all 71 residents. During a kitchen tour, it was observed that the Dietary Manager (DM) did not have test strips to verify the chemical levels in the sanitization buckets, as the existing strips had expired. The DM had informed the Executive Director (ED) about the expired strips, but due to a backorder from their supplier, new strips had not yet arrived. This lack of testing capability meant that the sanitization solution's effectiveness could not be confirmed. Additionally, the walk-in refrigerator was found to have a brown fuzzy substance on the storage racks, which the DM had been aware of since assuming her position. Despite attempts to clean it, the substance remained, and although cleaning supplies and a power washer were available, the cleaning had not been completed. The facility's policies did not adequately address the sanitization requirements for the buckets, and the cleaning policy indicated that the walk-in refrigerator and racks should be cleaned regularly, which was not adhered to.
Improper Food Storage and Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to adhere to proper food storage and hygiene practices in the kitchen, potentially affecting all 57 residents. During a kitchen tour, it was observed that silverware was improperly stored with handles facing downward, contrary to the facility's policy. In the dry storage room, opened packages of food items were inadequately sealed with non-sticking masking tape, and bottles of syrup were left open without lids, exposing them to air. In the walk-in cooler, an opened bag of celery was improperly stored with the celery resting directly on the shelf. Additionally, a staff member was observed not wearing a beard cover while serving food, which is against the facility's dress code policy. The kitchen environment was also found to be unclean, with a large cobweb on the stove hood and fuzzy debris on the sprinkler heads. Debris was hanging from the ceiling around a vent over the food preparation counters, and the light fixtures above these counters were covered in thick debris, with some containing dead insects. The Dietary Supervisor indicated that attempts to clean the ceiling resulted in flaking, and there was uncertainty about the cleaning of light fixtures. These observations highlight a failure to maintain cleanliness and hygiene standards in food preparation and storage areas, as outlined in the facility's policies.
Kitchen Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and well-repaired state, potentially affecting all 57 residents. During a tour of the kitchen, several issues were observed, including missing baseboards behind the ice chest, a cracked wall corner cover by the handwashing sink, and missing tiles in various areas such as underneath the dishwasher counter, the three-compartment sink, and in front of the back kitchen door. The dry storage room was found to have a significant amount of dirt and debris, including macaroni, on the floor against the baseboards underneath the food storage racks, with the baseboard peeling away from the wall in the corner. Additionally, a solidified brown liquid substance was found on the floor underneath one of the racks, which the Dietary Supervisor (DS) suggested might be from previous banana boxes. The walk-in cooler had spills all over the floor, with one area possibly being old rust with liquid over it, and there were cracked and missing floor tiles underneath the steamer. The facility's weekly kitchen cleaning logs from August 2024 to the present were reviewed, revealing that several areas had not been signed off as cleaned for multiple weeks. These areas included the walls and baseboards from the walk-in cooler to around the back door, both prep tables in the back area, the cook's help table on the serving line, the walls and baseboards behind all dish carts on the clean side of the dish area, and the refrigerator/freezer next to the sink. Furthermore, the cleaning logs for the first three weeks of August 2024 were missing entirely. The facility's Cleaning Equipment Policy and Procedures, provided by the Director of Nursing, stated that the walk-in refrigerator floor should be swept and mopped at least once a week, and the racks should be removed, and the floors and walls scrubbed with a sanitizing agent at least once a year.
Inadequate Redirection of Wandering Residents in Memory Care Unit
Penalty
Summary
The facility failed to adequately redirect residents with dementia who exhibited wandering behaviors, leading to a lack of privacy for other residents. Specifically, five residents with dementia were observed entering other residents' rooms uninvited, which was not addressed by staff. For instance, Resident 22, diagnosed with dementia, frequently wandered into other residents' rooms, including Resident 157's room, without staff intervention. This behavior was noted to occur multiple times a day, causing distress to the residents whose privacy was invaded. The care plans for residents with wandering behaviors, such as Residents 22, 41, and 27, included goals and interventions to manage these behaviors. However, the interventions were not effectively implemented. For example, Resident 27 was observed wandering into an empty room without staff redirection, and there were no structured activities available to engage her. Similarly, Resident 41's care plan included interventions to protect the rights and safety of others, but these were not consistently applied, as evidenced by her intrusive wandering behavior. Interviews with staff revealed a lack of structured activities and inadequate supervision on the memory care unit. LPNs reported attempting to redirect residents with snacks or music, but there was no regular activity staff to provide consistent engagement. The facility's policies on elopement and dementia care emphasized the need for adequate supervision and person-centered care plans, but these were not effectively executed, resulting in repeated incidents of residents entering others' rooms uninvited.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to accurately document a resident's code status in the clinical record, leading to a discrepancy between the resident's POST form and the physician's recapitulation orders. Resident 40's POST form, signed by both the resident and the physician, indicated that the resident was to receive CPR in the event of no pulse and no breathing. However, the physician's recapitulation orders stated that the resident was not to be resuscitated under the same circumstances. This inconsistency highlights a failure in the facility's documentation process. Interviews with the Director of Nursing (DON) and the Social Service Director revealed gaps in the facility's procedures for maintaining and communicating residents' code statuses. The DON indicated that the discrepancy might have occurred when Resident 40 was readmitted, and a floor nurse had the resident sign the POST form without proper explanation. Additionally, the Social Service Director admitted to not maintaining an ongoing binder with residents' current code statuses, contrary to the facility's policy. This lack of coordination and adherence to policy contributed to the failure in accurately documenting the resident's advanced directives.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately encode Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For Resident 44, the clinical record review revealed a discrepancy in the MDS assessment dated 9/4/2024, which inaccurately indicated that the resident had a six-month or less life expectancy without receiving hospice services. However, the hospice plan of care showed that Resident 44 had been admitted to hospice on 7/31/2023 and had been receiving hospice services continuously since then. The MDS Coordinator confirmed the error during an interview, acknowledging that the MDS assessment was coded inaccurately. Similarly, for Resident 53, the Admission MDS assessment dated 8/13/2024 incorrectly indicated that the resident received anticoagulant medication in the seven days prior to the admission reference date. However, the physician orders provided by the facility did not include any order for anticoagulant medication for Resident 53. The MDS Coordinator confirmed that the resident had not been on an anticoagulant during the review period, and the assessment was coded in error. The facility's policy on conducting accurate resident assessments was not adhered to, resulting in these inaccuracies.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for a resident, identified as Resident 10, who was reviewed for care plans. Resident 10's clinical record, reviewed on September 30, 2024, showed diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and major depressive disorder. During an interview on September 26, 2024, Resident 10, who was cognitively intact according to the Quarterly Minimum Data Set assessment dated August 27, 2024, indicated they did not recall having care plan meetings. The electronic health record revealed that the last comprehensive care plan meeting for Resident 10 was held on December 14, 2023, with no further meetings until July 1, 2024. The Social Service Director, interviewed on October 1, 2024, was unable to find records of care plan meetings for Resident 10 and stated that social services were responsible for setting up these meetings, which were supposed to be conducted quarterly and as needed. The facility's Comprehensive Care Plan policy, provided by the Director of Nursing, emphasized the resident's right to be informed of and participate in care planning, with care plan conferences scheduled regularly.
Incomplete Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to conduct complete neurological checks, including vital signs, for a resident who experienced an unwitnessed fall. Resident B, who had a history of falls and required substantial assistance, was found on the floor with skin tears after a fall in the bathroom. Despite the facility's policy requiring neurological assessments after unwitnessed falls, the documentation showed gaps in the checks, with a missing entry on 8/3/24 at 10:45 p.m. and no vital signs recorded after 8/3/24 at 9:14 p.m. Resident B's clinical record indicated multiple health issues, including dementia and repeated falls, and the resident was noted to be alert only to person with impaired memory after the fall. The resident was later sent to the hospital due to being unresponsive, highlighting the incomplete neurological monitoring. The facility's policy required frequent neurological assessments post-fall, but these were not fully adhered to, as evidenced by the incomplete documentation and the resident's subsequent condition.
Failure to Implement and Evaluate Behavioral Health Care Plan
Penalty
Summary
The facility failed to ensure a resident's plan of care for behavioral health was implemented and evaluated after the resident exhibited physical behavioral symptoms towards staff and other residents. Resident E, diagnosed with Huntington's disease, schizophrenia, and other conditions, had multiple incidents of physical aggression that were not adequately documented or addressed. The care plans for Resident E had not been updated with new interventions since 2021 and 2023, despite ongoing aggressive behaviors. The facility also failed to document the reasoning for administering intramuscular injections of antianxiety and antipsychotic medications and did not report these incidents to the Indiana Department of Health. On multiple occasions, Resident E exhibited aggressive behaviors, including grabbing another resident's arm, causing a skin tear and bruising, and attempting to choke Resident F, resulting in redness and fear. These incidents were not followed up with appropriate documentation or root cause analysis. Additionally, there were no follow-up notes in Resident E's clinical record to indicate if the underlying cause of the physical contact was discussed or determined. The facility's behavior management policy was not effectively implemented, as evidenced by the lack of behavior tracking and interdisciplinary team discussions. Interviews with staff revealed concerns about Resident E's unpredictable behaviors and the difficulty in communicating with him. Observations showed that Resident E was often left unsupervised in common areas, increasing the risk of further incidents. The facility's failure to provide necessary behavioral health care and services, document interventions, and ensure the safety of other residents during behavioral episodes led to significant deficiencies in the care provided to Resident E and other residents involved.
Failure to Address Inappropriate Behaviors in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia had a care plan with resident-specific interventions regarding inappropriate comments towards staff, monitoring of behaviors, and documentation of such behaviors in the clinical record. Resident H, who had a history of sexually inappropriate behavior, did not have a care plan that included interventions to address these behaviors. Despite being on medication for sexual behavior, Resident H continued to exhibit inappropriate behaviors, which were not adequately monitored or documented in the clinical record. Resident H was found to have touched another resident, Resident G, inappropriately on multiple occasions. The facility's response included placing Resident H on 1:1 supervision and moving him to a different room. However, the care plan for Resident H's sexually inappropriate behaviors was not revised to include effective interventions. Additionally, Resident H's behavior continued, leading to another incident involving Resident J, where Resident H attempted to touch her inappropriately. Interviews with staff indicated that Resident H had a history of sexually inappropriate behavior towards staff and other residents. The facility's policy on dementia care emphasized the need for individualized care plans and ongoing monitoring of interventions, but these were not effectively implemented for Resident H. The lack of appropriate interventions and monitoring led to repeated incidents of inappropriate behavior, compromising the safety and well-being of other residents.
Failure to Administer and Document Narcotic Medication
Penalty
Summary
The facility failed to ensure narcotic medication was administered per physician orders for two residents. Resident E, diagnosed with Huntington's disease and other conditions, had multiple instances where diazepam was not documented as administered according to the narcotic log sheets. Specific dates and times were noted where the medication was not recorded, indicating a failure in proper medication administration and documentation. Resident D, who was cognitively intact and diagnosed with heart failure, fibromyalgia, anxiety disorder, and low back pain, reported issues with receiving her scheduled pain medication. The narcotic log sheets for her Norco tablets showed several dates and times where the medication was not documented as administered. The facility's policies on controlled substance storage and medication administration were not followed, leading to these deficiencies.
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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) |
|---|---|---|---|---|
| Especially Kidz Health & Rehab | 0 mi | ★★★★★ | 6 | 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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