Health inspection·September 27, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to safely transport R1 after a shower to prevent a traumatic fall. This failure resulted in R1 falling from a shower chair to the floor causing multiple back and neck fractures requiring emergency medical evaluation and treatment at two hospitals. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list (9/25/2024) documents R1's diagnoses include Spastic Paraplegia (inherited neurological disorder causing muscle weakness and difficulty or inability to walk), Abnormal Posture, Difficulty in Walking, and Muscle Wasting and Atrophy. R1's quarterly assessment (7/24/2024) documents R1 has upper and lower extremity impairment limiting range of motion, is completely dependent on staff for all activities of daily living and utilizes a wheelchair for locomotion. The same record documents R1 is dependent on staff assistance for mobility while using a wheelchair. The facility incident report (9/13/2024) documents on 9/13/2024 at 8:50AM, facility staff were moving R1 on a shower chair from a shower stall when a wheel on the chair became caught on the shower curb and R1 fell from the chair to the ground and expressed pain. The facility incident investigation (9/13/2024) documents R1 complained of neck, chest, abdomen, and knee pain after falling to the ground on 9/13/2024. R1's progress notes (9/13/2024) documents R1 stayed in bed during lunch and only ate about six bites due to experiencing chest and abdomen pain. The same record documents R1 was sent to the local hospital emergency department for evaluation. The hospital emergency department report (9/13/2024) documents R1 presented to the department due to a fall and head, neck, chest, and lower back pain. The same report documents R1 reported experiencing pain everywhere and was diagnosed with neck and back fractures requiring transfer to a regional trauma center for further evaluation. The trauma center report (9/13/2024) documents R1 was diagnosed with six back and neck fractures (thoracic vertebrae #11/#12, lumbar vertebrae #1/#2/#3, and cervical vertebrae #3) and received intravenous morphine (narcotic pain medication used to treat severe pain) while at the regional trauma center. The same reports documents R1 remained an inpatient at the trauma center from 9/13/2024-9/18/2024 when R1 transferred back to the nursing home facility with an order for analgesic pain medication (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 09/27/2024 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)