Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to honor residents' right to dignity by failing to
provide timely toileting needs for a resident and by staff talking amongst themselves throughout residents'
meal service, while providing feeding assistance to residents. These failure affected seven residents (R5,
R27, R30, R41, R46, R62 and R80) out of 35 residents reviewed for dignity on the sample list of 35.
Findings Include:
1.) On 6/4/24 at 11:30 am, R62 stated she uses a bedpan. Staff has to help her, and she waits for long
periods to go, and has to hold it. If they don't come quick enough R62 (voids of bowel and bladder) in the
bed, then staff have to clean her up.
R62's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score
of 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents R62 is always
continent of bowel and bladder.
R62's Care Plan dated 05/05/2024 documents the following: (R62) requires assistance of 2 (two) staff for
transfers, ambulation, and bed mobility due to decreased strength. Category: Activities of Daily Living
Functional Status/Rehabilitation Potential The same Care plan documents: (R62) will ambulate to
bathroom, in her room utilizing staff assist x 2 (x/times two staff) and FWW (front wheeled walker).
On 6/5/24 at 11:20 am R62 was lying in a bariatric bed. V62 stated she cannot reposition herself without
staff assistance. R62 then stated I really hate to lay in (bladder and bowel excretions). It has happened
repeatedly where I am left laying in it. I haven't wet the bed since I was a child. This is terribly humiliating. I
can't tell you how bad it makes me feel. R62 also stated I have told the CNA's and nurses that this is
unacceptable. It falls on deaf ears. I have had to wait close to an hour, dirty (soiled in incontinence).
On 6/6/24 at 12:45 am V1, Administrator/ Registered Nurse stated V1 is aware R62 has verbalized Certified
Nursing Assistants have delayed answering R62 call light. V1 also stated I don't think anyone would want to
lay in bed soiled, for any length of time. Yes, this is a dignity issue.
The facility policy Call Light dated revised: January 2004 documents the following:
Objectives: 1. To respond to resident's request and needs.
(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 17
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
06/07/2024
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)
F 0550
Equipment: 1. Functioning call light.
Level of Harm - Minimal harm
or potential for actual harm
Procedure:
Key Points:
Residents Affected - Some
1. Answer call light promptly.
2.
Knock before entering room.
3.
Turn off call light.
4.
Listen to resident's request. Do not make him/her feel that you are too busy to help.
5.
Respond to request. If item is not available, or request questionable, get assistance from nurse. Return to
resident with prompt reply.
2.) R5's Minimum Data Set (MDS) dated [DATE] document R5 has severe cognitive impairment.
R27's MDS documents dated 5/22/24 R27 has severe cognitive impairment.
R30's MDS dated also 5/22/24 documents R30 has severe cognitive impairment.
R41's MDS dated [DATE] documents R41 has severe cognitive impairment.
R46 MDS dated [DATE] documents R46 has severe cognitive impairment.
R80's MDS dated [DATE] documents R80 has severe cognitive impairment.
On 6/5/23 at 12:12 PM - 12:20 PM V10, MDS Coordinator/Licensed Practical Nurse (LPN) sat down to
provide feeding assistants to R46. V10, talked to V13, Certified Nursing Assistant (CNA) who was providing
feeding assistance to R41, and V16, CNA was providing feeding assistance for R46. V10, MDS
Coordinator/LPN, V13 CNA and V16 CNA engaged in conversation with each other about their off-work
activities. V10, V13 and V16 would intermittently pause from personal conversations to give short directions
to the residents, (i.e drink, open your mouth, bite). R5 slept at the table after limited offers by V10, to take a
bite of food.
On 6/5/24 at 12:25 PM -12:30 V13, CNA and V16, CNA remained at the first table providing feeding
assistance. V16, CNA was assisting R46. V13, CNA continued to assist R41. R5 remained asleep at the
table. At a second table in the main dining room, approximately, six feet away from the first assisted dining
table, V9, Registered Nurse (RN), was providing assistance to R30, and V15, CNA was feeding
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 2 of 17
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
06/07/2024
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)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R80. V8, CNA, V9, RN, V15, CNA talked across the room to the staff at the first table still assisting
residents to dine. The staff were loud and spoke minimally to the residents and continued to speak of
events outside/unrelated to the facility or resident care.
On 6/5/24 at 12:40 PM V10, LPN acknowledged staff were engaged in personal conversations and should
have been talking to the residents.
3.) On 6/6/24 at 12:20 PM -12:35 PM at the first table, in the main dining room V11, CNA was providing
feeding assistance to R46. V27, CNA was providing feeding assistance to R5, V9 RN was providing feeding
assistance to R41, and V10, LPN was providing feeding assistance to R27. All staff at the first table were
minimally interacting with their respective resident. Staff discussed outside of work family activities with
short directions given to the residents to open their mouth, take a drink, swallow etc. while talking about
events outside of work.
On 6/6/24 at 12:45 am V1, Administrator/ Registered Nurse acknowledged it is a dignity issue for staff to
engage in conversation unrelated to work. Staff should be engaging in conversations with the residents.
The facility Residents' Rights Pamphlet revised November 2018 documents the following:
for People in Long-Term Care Facilities documents the following: As a long-term care resident in Illinois, you
are guaranteed certain rights, protections and privileges according to state and federal laws. and
Your rights to dignity and respect,
*
You have a right to make your own choices.
*
Your facility must treat you with dignity and respect and must care for you in a manner that promotes your
quality of life.
*
Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment
source.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 3 of 17
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
06/07/2024
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on interview and record review the facility failed to report an allegation of verbal and physical abuse
of a resident by a staff member to the Abuse Coordinator. This failure affects one (R1) resident reviewed for
abuse on the sample list of 35.
Findings include:
R1's undated Face Sheet documents R1's medical diagnoses of Postural Kyphosis, Hypertension, Anxiety
Disorder, Altered Mental Status, Dysuria, Overactive Bladder, Open Angle Glaucoma, Corneal Edema and
Macular Degeneration.
R1's Abuse Investigation dated 4/12/24 documents V29 (R1's Power of Attorney/POA) alleged that V28
Certified Nurse Aide (CNA) was 'rough' with R1 during cares, yelled at and was rude to R1 and left R1 in
wet clothes after providing a shower to R1.
On 6/6/24 at 11:50 AM V1 Administrator stated V1 was made aware of this incident on 6/6/24. V1
Administrator stated I never knew anything about this. It was not reported because this is the first, I am
hearing about it. I will report it now.
On 6/6/24 at 12:00 PM V2 Director of Nurses (DON) stated V28 Certified Nurse Aide (CNA) was given a
written warning after R1's family complained about his care for R1. V2 stated there was an investigation
done at that time and V28 CNA was suspended. V2 DON stated V28 was also on vacation, so the
suspension overlapped V28's vacation time. V2 DON stated V28 was not in the facility until the investigation
was completed.
The facility policy titled 'Abuse Prohibition and Reporting' revised 11/28/2019 documents the facility
employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report
the matter to the facility Administrator or designee. If the allegation involves the Administrator, then the
facility employ or agent should immediately report the matter to the facility Director of Nurses (DON).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 4 of 17
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
06/07/2024
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)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to follow physician orders one (R339) resident
reviewed for infection in the sample list of 35 residents.
Residents Affected - Few
Findings include:
R339's undated Face Sheet documents R339's diagnosis as: Enterocolitis due to Clostridium Difficile, not
specified as recurrent.
R339's Care Plan dated 5/24/24, documents administer antibiotics as ordered.
R339's Discharge Documentation dated 5/23/24, documents R339 discharged on 5/23/24. This same
discharge documents R339's Primary Discharge Diagnosis as Clostridium Difficile.
R339's Patient Discharge Instructions dated 5/23/24, documents Fidaxomicin 200 milligrams (mg) oral
tablet 1 tablet oral two times a day for ten days; last dose 5/23/24 AM, next dose 5/23/24 PM.
R339's Medication Administration Record (MAR) dated 5/23/24 - 6/7/24, documents Dificid (fidaxomicin)
200 mg tablet by mouth twice a day. This same MAR documents this antibiotic as not given on 5/23/24 PM
dose as it documents on the discharge instructions to be given; not given on 5/26/24, twice a day; and
5/27/24 not given the AM dose.
On 6/7/24, V3 Registered Nurse (RN) stated it look like Dificid (fidaxomicin) was not given to R339 on
5/23/24, PM dose, not given at all on 5/26/24, not given on 5/27/24 AM dose, not given on 5/29/24 AM
dose. V3 stated the nurses should follow the physician orders and give medications as ordered.
The facility's Medication Administration Policy dated Revised 2/04, documents to provide the resident with
medications deemed necessary by the physician to improve/stabilize specified diagnoses of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 5 of 17
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
06/07/2024
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to prevent cross contamination during urinary
catheter care for one (R55) resident out of four residents reviewed for Catheter Care in a sample list of 35
residents.
Findings include:
R55's undated Face Sheet documents R55's medical diagnoses as Parkinson's Disease, Malignant
Neoplasm of Prostate, Bladder-Neck Obstruction, Emphysema, Macular Degeneration, Muscle Wasting
and Atrophy, Weakness, and history of Traumatic Subdural Hemorrhage with loss of conscious and
Shortness of Breath
R55's Physician Order Sheet (POS) dated June 2024 documents a physician order to provide urinary
catheter care every shift.
R55's Minimum Data Set (MDS) dated [DATE] documents R55 as cognitively intact. This same MDS
documents R55 as dependent on staff for bathing, personal hygiene, and toileting.
On 6/6/24 at 10:30 AM V11 Certified Nurse Aide (CNA) completed urinary catheter care for R55. V11 CNA
wore the same pair of gloves through the entire procedure. V11 CNA did not change gloves nor use hand
hygiene after contaminating gloves with stool and then cleaning R55's urinary catheter tubing. V11 CNA
swiped back of V11's Right Hand in R55's stool causing visible layer and streaks of stool on back of V11's
Right Hand. V11 CNA then used contaminated gloves to provide urinary catheter care for R55.
On 6/6/24 at 10:40 AM V11 Certified Nurse Aide (CNA) stated V11 should have changed gloves after
providing bowel incontinence care and catheter care for R55.
On 6/6/24 at 11:00 AM V9 Infection Preventionist (IP) stated hand hygiene is an important part of reducing
the risk of infections. V9 IP stated staff should always change gloves when gloves become contaminated.
V9 IP stated R55 could be at a higher risk of infection due to improper urinary catheter care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 6 of 17
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
06/07/2024
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review the facility failed to maintain and store respiratory equipment in
a clean sanitary manner, off the floor and failed to date respiratory equipment when changed. These
failures affected four of seven residents (R8, R30, R33, R55) reviewed for respiratory/oxygen on the sample
list of 35.
Residents Affected - Some
Findings Include:
The facility's Oxygen Therapy policy dated 3/16/17 documents it is the policy of the facility to provide a
source of oxygen to persons experiencing an insufficient supply of oxygen. The humidifier bottles will be
attached to the tank flow meter. Oxygen set-up (cannula/mask, tubing) must be exchanged every seven
days.
On 6/6/24 at 12:30 PM V3 Registered Nurse/Nurse Manager confirmed respiratory equipment should be
stored in a sanitary way (a bag) in order to keep tubing and masks off of the floor and other surfaces. V3
also confirmed oxygen humidifier bottles should be off the floor and connected to the oxygen concentrator.
V3 also confirmed nebulizer masks, tubing and nasal cannula tubing should be dated with the date it was
last changed.
1) R8's Face Sheet dated June 2024 documents R8 is diagnosed with Pneumonia and Bronchitis.
R8's Physician Order Sheet dated June 2024 documents an order for Oxygen 2-4 liters per nasal cannula
as needed for shortness of breath.
On 6/05/24 at 12:37 PM R8's oxygen concentrator was in her room with oxygen tubing attached. There was
no date on the tubing and tubing was laid over the bed and bed frame with no bad available for sanitary
storage.
2.) R33's Face Sheet dated June 2024 documents R33 is diagnosed with Pneumonia, Shortness of Breath,
and Chronic Obstructive Pulmonary Disorder.
R33's Physician Order Sheet dated June 2024 documents an order for Oxygen at 2 liters per nasal cannula
continuously for Shortness of Breath.
On 6/05/24 at 12:35 PM R33's oxygen concentrator was in her room with tubing attached. The tubing was
on the floor and bed with no bag available for sanitary storage.
3.) R55's undated Face Sheet documents R55's medical diagnoses as Parkinson's Disease, Malignant
Neoplasm of Prostate, Bladder-Neck Obstruction, Emphysema, Macular Degeneration, Muscle Wasting
and Atrophy, Weakness, and history of Traumatic Subdural Hemorrhage with loss of conscious and
Shortness of Breath
R55's Physician Order Sheet (POS) dated June 2024 documents a physician order for R55 to use Two liters
of Oxygen per nasal cannula continuously.
R55's Minimum Data Set (MDS) dated [DATE] documents R55 as cognitively intact. This same MDS
documents R55 as dependent on staff for bathing, personal hygiene, and toileting.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 7 of 17
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
06/07/2024
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 6/6/24 at 10:40 AM R55 was lying in bed wearing his nasal cannula connected to R55's Oxygen
humidifier bottle. R55's Oxygen humidifier bottle was sitting on the floor next to R55's Oxygen Concentrator.
R55's floor was littered with multiple pieces of small debris and dust.
On 6/6/24 at 12:40 PM V9 Infection Preventionist confirmed R55's Oxygen humidifier bottle was sitting on
R55's dirty floor. V9 IP stated all Oxygen supplies should be off of the floor and maintained in a 'more
hygienic way'. V9 IP stated R55's Oxygen concentrator has a specialized area to contain the humidifier
bottle but that the strap to hold in the humidifier bottle had broken. R30's undated Face Sheet documents
R30's medical diagnoses as Dementia, Respiratory Distress, Wheezing, Hypoxemia, Shortness of Breath,
and Dyspnea.
4.) R30's Physician Order Sheet (POS) dated June 2024 documents a physician order for Albuterol Sulfate
0.083% solution for nebulization; 2.5 milligram (mg) /3 milliliter (ml) per vial. Give one vial per inhalation
every four hours as needed. This same POS documents a physician order to change the Nebulizer tubing
every two weeks.
On 6/4/24 at 11:00 AM R30's nebulizer face mask was dated 3/10/24 and sitting on top of a dirty sock on
top of R30's bedside dresser. R30's nebulizer face mask was not in a bag.
On 6/6/24 at 1:00 PM V3 Nurse Manager stated all Nebulizer tubing should be placed in a plastic bag when
not in use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 8 of 17
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
06/07/2024
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on interview and record review the facility failed to complete Psychotropic Medication Assessments
for two of five (R43, R343) residents reviewed for Unnecessary Medications in the sample list of 35.
Findings Include:
The Psychopharmacological Drug Usage Procedure dated 10/18/17 documents a Psychopharmacological
Drug is a medication used for managing behavior, stabilizing mood, or treating psychiatric disorders.
Residents using psychopharmacological medications must have an initial assessment with quarterly
reassessments to provide a data base for the Care Plan and Gradual Dose Reduction Program.
1. R43's Face Sheet dated June 2024 documents R43 is diagnosed with Dementia with Behavioral
Disturbances and Depression.
R43's Physician Order Sheet dated June 2024 documents R43 is prescribed Citalopram (Antidepressant)
15 milligrams daily and Olanzapine (Antipsychotic) 2.5 milligrams daily.
On 6/6/24 at 3:30 PM V3 Registered Nurse (RN) Nurse Manager confirmed R43 has not had a
Psychopathological Observation (Assessment) in the last year.
2. R343's Face Sheet dated June 2024 documents R343 is diagnosed with Depression and Generalized
Anxiety.
R343's Physician Order Sheet dated June 2024 documents R343 is prescribed Buspar 15 milligrams twice
per day and Citalopram 20 milligrams daily.
On 6/6/24 at 3:30 PM V3 Registered Nurse (RN) Nurse Manager confirmed R343 has not had an Initial
Psychopathological Observation (Assessment). R343 was admitted on the medications and should have
has an assessment on admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 9 of 17
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
06/07/2024
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)
F 0801
Level of Harm - Minimal harm
or potential for actual harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on observation, interview, and record review the facility failed to employ a Certified Dietary Manager.
This failure has the potential to affect all 80 residents residing in facility.
Residents Affected - Many
Findings include:
The facility Long-Term Care Facility Application for Medicare and Medicaid dated 6/04/2024 documents 80
residents reside in the facility.
On 6/4/24-6/7/24 through daily rounding in the dietary department there were no observations made of a
Certified Dietary Manager.
On 6/4/24 at 11:50 AM facility kitchen staff were carrying out the daily dietary duties, plating and serving
lunch meal and preparing foods for the next meal.
On 6/4/24 at 11:55 AM V7 Dietary Aide stated the facility has not had a dietary manager in 'almost a year'.
On 6/5/24 at 9:45 AM V1 Administrator confirmed the facility does not have a Certified/Dietary Manager. V1
stated the role has been empty for six months. V1 stated the facility has made an offer to a perspective DM
but has not hired anyone yet. V1 stated the Registered Dietician (RD) is onsite monthly and reviews
resident charts remotely every week. V1 stated the RD is not onsite full time. V1 Administrator stated the
facility does not have a policy that states there must be a Certified Dietary Manager, but facility is supposed
to have a Certified Dietary Manager and does not.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 10 of 17
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
06/07/2024
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)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to provide meals at a palatable temperature for
two residents (R51, R52) out of two residents reviewed for meal service in a sample list of 35 residents.
Residents Affected - Few
Findings include:
The facility dietary spreadsheet titled 'Week at a Glance Week One' documents the lunch meal for 6/5/24
consisted of beef cutlet with gravy, baked potato with sour cream and margarine, copper penny salad,
bread and margarine, Jello cake with whipped topping and a beverage.
1.) R51's Minimum Data Set (MDS) dated [DATE] documents R51 as cognitively intact.
R51's Physician Order Sheet (POS) dated June 2024 documents a physician order for a regular
consistency diet.
On 6/5/24 at 12:29 PM R51 stated the food is cold. R51 stated By the time the food gets to my room it is
cold. I don't like eating in the dining room like cattle. The gravy on today's meat was ice cold. I tried one bite
and that was enough.
On 6/5/24 at 12:00 PM V24 walked R51's lunch meal from holding bin sitting at entrance of hall to R51's
room (four rooms down from holding bin) without a cover over food.
On 6/5/24 at 12:30 PM R51 was sitting in her recliner chair in her room. R51's ate approximately 10% of
her lunch. R51 had taken one bite out of her beef cutlet with gravy.
2.) R52's Minimum Data Set (MDS) dated [DATE] documents R52 as moderately cognitively intact.
R52's Physician Order Sheet (POS) dated June 2024 documents a physician order for a regular
consistency diet.
On 6/5/24 at 12:00 PM V24 walked R52's lunch meal from holding bin sitting at entrance of hallway to R52's
room (five rooms down from holding bin) without a cover over food.
On 6/5/24 at 12:32 PM R52 was sitting in her wheelchair in her room. R52 ate approximately 25% of her
lunch meal. R52 had taken two bites out of her beef cutlet with gravy.
On 6/5/24 at 12:33 PM R52 stated My food is usually cold. That gravy was as cold as ice. I don't eat cold
food. They (staff) should know better.
On 6/5/24 at 12:40 PM V24 [NAME] stated the staff do not cover the residents food trays when delivering
the meals to the residents. V24 stated That would be a good idea. There are usually some residents who
complain the food is cold.
On 6/6/24 at 2:45 PM V3 Nurse Manager stated the resident's meal trays should be covered when the staff
are carrying the food trays from the holding bin to the resident rooms. V3 stated the food would likely be
cold if it is not kept covered. V3 Nurse Manager stated I don't think there is a policy on this, but it would just
make sense. That way the residents would complain less about getting
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 11 of 17
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
06/07/2024
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)
F 0804
served cold food.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 12 of 17
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
06/07/2024
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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to serve a modified diet as ordered for one (R41)
of six residents reviewed for dining on the sample list of 35.
Findings include:
R41's Minimum Data Set, dated [DATE] documents R41 has severe cognitive impairment.
R41's Physician Order Sheet documents R41's diet order start date was 7/22/22 as follows: Diet is to be
liquidized with nectar thick liquids.
On 6/5/24 at 12:00 PM, R41 being fed by V13, Certified Nursing Assistant (CNA). V13, CNA feed R41 by
pouring R41's pureed liquidized foods by nosey cups into R41's mouth. The pureed food was pureed then
thickened to a nectar consistency. R41's meal consisted of a beef cutlet with gravy, mashed potatoes and
strawberry cake, and thickened nectar consistency beverages. R41's also had watered down-like tomatoes
soup, un-thickened. V13, CNA fed R41 the watered down like tomatoes soup via a nosey cup. R41 started
coughing, immediately and repeatedly. V10, Licensed Practical Nurse/Minimum Data Set Coordinator who
was across the table assisting another resident. V10 directed V13, CNA to 'give R41 a break'. V13 stopped
feeding R41 who continued to cough repeatedly for several minutes.
On 6/5/24 at 12:35 PM V13, CNA stated I stopped giving her (R41) the tomatoes soup. That is what she
was choking on. It was too thin. The kitchen is supposed to thicken (R41) drinks before we serve them.
On 6/6/24 at 9:38 am V24, cook stated I was training (V25, Cook) yesterday. (R41) gets tomatoes soup
instead of some vegetables. (R41) is the only resident that received the tomatoes soup yesterday. (V25)
prepared (R41's) soup, but I will take full responsible for not thickening it. I know it was supposed to be and
I missed it when training (V25).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 13 of 17
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
06/07/2024
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a
clean sanitary condition, to prevent potential cross-contamination and potential food-borne illness and failed
to dispose of outdated dry storage food products. This failure has the potential to affect all 80 residents
residing in the facility.
Findings include:
On 6/6/24 between 9:05 am - 10:45 am during the kitchen tour intermittently with V23, Head [NAME] and
V24, Cook.
1.) On 6/6/24 at 9:05 am the commercial ice machine was soiled with a built- up of rust on the bolts of the
top angled door that hung inside over the ice. V24 confirmed the observation and stated, 'that needs to be
cleaned.'
2.) On 6/6/24 at 9:08 am, the metal shelf under the commercial coffee maker containing numerous steam
table pan covers. The shelf was covered in rust. V24 confirmed the observation and stated the facility has
had a problem with the coffee maker leaking for a long time, and maintenance will have to look at this.
3.) On 6/6/24 at 9:12 am the countertop, under the commercial juice dispenser machine, had standing
water under it. The shelf below the juice dispenser contained four commercial sized multi-gallon boxed
containers of juices. The boxes of juice laid on top of the rusted metal shelf. V24, stated I will have to have
maintenance fix that leak too.
4.) On 6/6/24 at 9:15 am, the commercial two door refrigerator had two, open gallon plastic container of
lime juice. The plastic gallon containers document a manufacturers date to use by May 19, 2024. V24 stated
we don't use that very often. The distributor was out of lemon juice and brought this instead. We have a lot
of it in storage. We will have to get rid of it. Once opened, we have to discard food items in seven days.
5.) On 6/6/24 at 9:18 am, the facilities commercial grill had a three-inch side, that overhung that abutted the
commercial stove. The three-inch overhang had thick, brown and black, grease-like build-up and yellow
lines of thick liquid-like drips that adhered to the grease like surface. V24 stated The yellow (substance) is
from french toast I made yesterday; the rest (grease like stick build-up) has obviously been there awhile.
6.) On 6/6/24 at 9:22 am the approximately, three foot by two foot, back metal plate of the commercial
stove, had copious amount of dark brown and black, sticky grease-like accumulation. V24 stated I will have
to take a steel brush to that. It has not been cleaned for a while. We don't really have a cleaning schedule.
Looks like we need one though.
7.) On 6/6/24 at 9:25 am the double commercial ovens had charcoal-like build-up approximately an inch in
depth across the bottom of the double ovens. V24 stated.
That (oven) will have to be cleaned at night, after it cools off.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 14 of 17
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
06/07/2024
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
8.) On 6/6/24 at 9:28 am the table-top, commercial can opener had a build-up of rust and metal fragments
in the gears and the tip of the blade had the silver coating missing. V24 stated, We may have to just get a
new can opener. That is in pretty bad shape. We usually run it threw the dishwasher. That is not doing
(getting it cleaned) it.
9.) On 6/6/24 at 9:32 am V6, Preparation [NAME] confirmed observations in the dry storage room of the
following expired items: One - opened, half used, 14.5 ounce, thick and creamy pouch of instant cheese
mix manufactures use by date of 4/24/24, and no opened date. The dry storage room also had nine
additional pouches of instant cheese mix, with the same manufactures use by date of 4/24/24.
There were three, opened, five-pound bags of powdered devil food cake mix manufacturers use by date of
2/27/24 and three unopened five-pound bags of devil's food cake with manufacturers used by date of
3/30/24. V24 stated We have several cooks that do not rotate stock. I can tell you; we have used them all
recently.
10.) On 6/6/24 at 10:45 am V23, Head [NAME] confirmed the facility commercial dishwashing station had a
metal backsplash, approximately six inches high. The backsplash meets the wall, just above the dishwasher
running board. The backsplash had cracked, chipped chunks of loose caulking that spanned approximately
six feet across and above the dishwasher running board. V23 stated The county health already identified
that a couple weeks ago and it has not been fixed yet.
Adopted 08/ l 9 The facility policy Cleaning & Sanitizing Work Surfaces & Equipment Procedure documents
the following:
Objective: To provide guidelines to clear, clean and sanitize work surfaces and equipment.
Procedure: STEP 1: CLEARING WORK SURFACES & EQUIPMENT: Clear work surface tables of food,
food crumbs, dirty utensils, used cutting board, etc. Clear equipment such as grill, slicer, mixer, etc. of food
and food crumbs. Take apart equipment if possible and wash and sanitize parts in 3 compartment sink. If
the equipment cannot be washed and sanitized in the 3-compartment sink, follow the procedures below.
The facility Long-Term Care Facility Application for Medicare and Medicaid dated 6/04/2024 documents 80
residents reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 15 of 17
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
06/07/2024
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to prevent cross contamination during meal
service by not using hand hygiene when assisting residents to eat for five (R27, R40, R46, R56, R80)
residents out of five residents reviewed for Infection Control in a sample list of 35 residents.
Residents Affected - Some
Findings include:
1.) R56's undated Face Sheet documents R56's medical diagnoses as Diabetes Mellitus Type II,
Dysphagia, Anemia, History of Methylicillin Resistant Staphaureus (MRSA), History of Skin Infection,
Morbid Obesity and Heart Failure.
R56's Minimum Data Set (MDS) dated [DATE] documents R56 as requiring assistance with setting up her
meal tray.
On 6/5/24 at 11:40 AM V8 Certified Nurse Aide (CNA) used V8's bare hand to move R56's cut pieces of
beef cutlet from one side of R56's plate to the other side. V8 did not use hand hygiene and was not wearing
gloves. R56 then picked up her fork and ate the same pieces of beef cutlet that V8 CNA had moved with her
bare hand.
On 6/6/24 at 11:05 AM V8 Certified Nurse Aide (CNA) stated V8 should not have touched R56's food with
her bare hands. V8 CNA stated V8 should have worn gloves or used R56's utensils to move food around on
R56's plate.
2.) R27's undated Face Sheet documents R27's medical diagnoses as Alzheimer's Disease, Dysphagia,
Major Depression Disorder, Chronic Pain, and Tremors.
R27's Minimum Data Set (MDS) dated [DATE] documents R27 is dependent (helper does most or all of the
work) on staff for assistance with eating.
R46's undated Face Sheet documents R46's medical diagnoses as Alzheimer's Disease, Vascular
Dementia, Dysphagia, Cerebral Infarction, Gastro-Esophageal Reflux Disease (GERD) and Vitamin
Deficiency.
R46's Minimum Data Set (MDS) dated [DATE] documents R46 as dependent (helper does all of the effort)
with assistance in eating.
On 6/4/24 at 12:20 PM V10 Licensed Practical Nurse (LPN) assisted both R27 and R46 throughout the
lunch meal. V10 assisted R27 and then without using hand hygiene or Alcohol Based Hand Rub (ABHR)
assisted R46 multiple times during lunch meal.
On 6/4/24 at 12:25 PM V10 Licensed Practical Nurse (LPN) assisted R27 with eating her lunch. V10
attempted to feed R27 a bite of chocolate cake which touched R27's lips but then fell down onto V10's Left
Wrist. V10 shook the piece of cake onto table, moved it towards the center of her table with her Right Hand
and then V10 LPN proceeded to use her Right Hand to assist R46 with eating her meal. V10 did not use
hand hygiene nor use alcohol-based hand rub (ABHR) prior to assisting R46 to eat her meal.
3.) R40's undated Face Sheet documents R40's medical diagnoses as Hereditary Spastic Paraplegia,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 16 of 17
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
06/07/2024
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)
F 0880
Gastro-Esophageal Reflux Disease and Dysphagia.
Level of Harm - Minimal harm
or potential for actual harm
R40's Minimum Data Set (MDS) dated [DATE] documents R40 as dependent (helper does all of the effort)
with assistance in eating.
Residents Affected - Some
R80's undated Face Sheet documents R80's medical diagnoses as Anorexia, Alzheimer's Disease,
Ventricular Premature Depolarization, Bradycardia, Dilated Cardiomyopathy and Vitamin Deficiency.
R80's Minimum Data Set (MDS) dated [DATE] documents R80 as requiring moderate assistance (helper
does less than half the work) for eating and oral hygiene.
On 6/4/24 at 12:15 PM V8 Certified Nurse Aide (CNA) assisted R40 with eating her lunch meal. V8 CNA
gave R40 a bite of food, then using both hands grabbed with table to reposition herself closer to R80. V8
then used contaminated Right Hand to pick up R80's drinking cup with palm placed directly over open top
of cup and straw positioned in between V8's fingers to give R80 a drink of water.
On 6/6/24 at 11:07 AM V8 Certified Nurse Aide (CNA) stated V8 should have used hand hygiene when
assisting two residents (R40, R80) eating their meals at the same time.
The facility policy titled 'Hand Washing Procedure' adopted August 2019 documents proper hand washing
is the most effective way to reduce microorganisms to prevent the spread of infection such as Influenza and
to prevent foodborne illness such as Norovirus. Facility staff should wash hands after touching clothes, face,
body, or hair, after handling soiled equipment, after handling dirty dishes and after engaging in any activity
that would contaminate hands. Hand antiseptic may be used AFTER washing hands and is not to be used
as a substitute for hand washing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145441
If continuation sheet
Page 17 of 17
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Back to topCitations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the June 7, 2024 survey of SHELBYVILLE MANOR?
This was a inspection survey of SHELBYVILLE MANOR on June 7, 2024. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SHELBYVILLE MANOR on June 7, 2024?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.