Inspection·November 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review the facility failed to ensure the right of being treated with respect and dignity for two (R1, R2) of four residents reviewed for abuse on the sample list of seven. Residents Affected - Few Findings include: 1.) The facility's abuse investigation dated 8/9/24 at 3:00 PM documents, V4 (Certified Nurse's Assistant) allegedly said to R2 that no one likes R2, and no one wants to answer R2's call light. This investigation documents that abuse was unsubstantiated because R2 may have misunderstood V4 as R2 is hard of hearing. This investigation documents V4 will be educated regarding how to speak to R2. On 11/8/24 at 9:09 AM, R2 stated V4 worked with R2 for 5 or 6 weeks straight. R2 stated V4 acted like V4 didn't want to talk to anyone. R2 stated if R2 asked V4 to do something V4 would say stuff like, Don't start that. R2 stated R2 has to go to the bathroom a lot because R2 drinks a lot of water to prevent UTIs (urinary tract infections). R2 stated R2 would try to hold it so R2 wouldn't have to ask V4 for help. R2 stated V4 acted like V4 didn't want to be bothered. R2 stated V4 acted like V4 didn't want to put R2 to bed. R2 stated V4 was smart alecky and mad at the world. R2 stated V4 didn't want to work. R2 stated V4 wasn't mean and V4 did what R2 asked but wasn't happy. On 11/8/24 at 1:36 PM, V2 Director of Nursing stated it was reported that V4 allegedly told R2 that no one likes R2, and no one wants to answer R2's call light. V2 stated V2 talked to V4 about V4's tone. V2 stated when V2 interviewed R2 about V4; R2 stated R2 felt rushed when V4 provided R2's cares. V4's In-service education dated 8/14/24 documents V4 was educated to be concise when speaking so that there is no misunderstanding of intent, speak clearly and ask questions to ensure satisfaction of care, monitor speaking tone, make eye contact, respect the residents and go at their pace with their cares and do not rush. 2.) The facility's abuse investigation dated 10/23/24 documents on 10/23/24 at 3:40 PM, R1 reported to V3 Social Service Director that V4 Certified Nurse's Assistant was coming into R1's room opening and closing the door for no apparent reason and V4 is just always angry. This report documents V3 reported this to V2 Director of Nursing. The conclusion of this investigation documents abuse was not substantiated but documents V4 is inappropriate with her communications with the residents. This investigation documents staff believe V4 to be rude, gruff, abrupt, and hateful in V4's tone when speaking to residents. (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 11/08/2024 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)