Inspection·March 13, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was free from abuse by another resident. This failure affects two (R3, R2) of three residents reviewed for abuse in a sample list of three. Findings Include: R3's Event Report dated [DATE] at 3:59PM documents (R3) was sitting in hallway when (R3) was approached by (R2) who struck (R3) in her right eye with a clenched hand. (R3) immediately stood up from chair and grabbed the (R2's) wrist and struck (R2) in the right jaw area with a clenched hand. Staff intervened immediately and both residents were separated. (R3's) right eye is slightly bloodshot and a cold compress was applied. (R3) remains angry and staff are sitting with (R3) at present. R3's Care Plan revised [DATE] documents the following diagnoses: Alzheimer's Dementia with Behavioral Disturbance, Mood Disturbance and Anxiety. This Care Plan also documents (R3) displays rejection of care behaviors such as refusing to change clothes when incontinence occurs, this behavior occurs infrequently. (R3) displays verbal behavior directed toward staff and others such as name calling and cussing. Physical behaviors displayed are hand gestures such as shaking fist at staff. (R3) frequently wanders into other resident's room and is not easily redirected at times. R3's Care Plan does not address R3's vulnerability to abuse. R2's Care Plan revised [DATE] documents the following diagnoses: Vascular Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. This Care Plan also documents (R2) has dementia with cognitive impairments, depression, brief psychotic disorder. At times (R2) displays behaviors including physical behaviors directed towards others, verbal behaviors directed towards others. (R2) at times will display hallucinations where (R2) sees relatives that are not present, both living and deceased . This is frequently a trigger for behaviors and can also lead to an increase in wandering and exit seeking in an attempt to get home. R2's MDS (Minimum Data Set) dated [DATE] documents R2 is severely cognitively impaired. R2's progress note dated [DATE] at 10:36AM documents During resident care, (R2) struck female staff member in the face with clenched hand. Staff intervened immediately and separated the two. (R2) redirected to residents' room with staff supervision. R2's Progress note dated [DATE] 10:52AM documents Staff reported to (V14), Dementia Director while in the dining room they observed (R2's) hands on another residents family members shoulder squeezing. Staff intervened immediately and redirected resident back to her room with supervision. On [DATE] at 2:00PM V3, Assistant Director of Nursing stated We realized R2's behavior was a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145441 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Manor 1111 West North 12th Street Shelbyville, IL 62565 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)