Inspection·July 22, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete CNA it hurt, the CNA replied, it will heal. This note documents a CNA reported R5 was bleeding in scrotum area. R5's Nursing Note dated 07/18/2025 at 6:39 PM documents V10 LPN assessed R5's scrotum which had a 2 centimeter (cm) by 1 cm open area, like skin was ripped, and blood noted in brief. This note documents R5 reported that he did not have a shower today but had one a couple days ago. V10 looked at the shower schedule and R5's showers are scheduled for Mondays and Thursdays. V10 obtained orders to apply barrier cream and Vitamin A & D ointment until healed. R5's Nursing Note dated 7/18/25 at 7:01 PM documents V1 Administrator returned call to the facility and was notified of R5's reported incident. R5's Nursing Note dated 07/18/2025 at 7:02 PM documents POA (Power of Attorney) was called about open area to scrotum and that due to the circumstance of how resident told how area got there will be investigated by administrator.On 7/22/25 at 11:30 AM V10 LPN was asked to describe any abuse allegations in the facility. V10 stated on 7/18/25 around 5:30 PM R5 had a bleeding scrotal skin tear and R5 reported to the CNAs that V13 CNA had given R5's shower that day and washed R5 hard, R5 told V13 to stop, and V13 said it will heal. V10 stated R5 had a 2 cm skin tear to his scrotum and R5 told V10 that it happened a few days prior. V10 stated V10 reported R5's allegation to V1 Administrator and R5's family immediately.On 7/22/25 at 12:36 PM V11 CNA stated on 7/18/25 around 5:30 PM V11 overheard R5 tell V15 CNA that V13 CNA gave R5 a shower on first shift, and V13 rubbed R5's scrotal area hard. V11 stated per R5, R5 told V13 to stop and V13 said it would be ok, it would heal. V11 stated the underside of R5's scrotum was bleeding and V10 was notified. V11 stated V11 considered this to be an abuse allegation and V10 reported the incident to V1.On 7/22/25 at 2:33 PM V15 CNA stated on the evening of 7/18/25 R5 told V15 that unidentified male CNA was rough with R5 during R5's shower. V15 stated R5 said R5 told the CNA to be more gentle and the CNA replied that he was just trying to get R5 clean. V15 stated there was blood in R5's brief and V15 reported this to the nurse.On 7/22/25 at 2:48 PM V1 Administrator stated on the evening of 7/18/25 R5 reported to staff that during his shower V13 CNA scrubbed a little hard and that it hurt. V1 stated that was all that was reported to V1. V1 stated V1 looked at R5's shower documentation and V13 had not given R5 a shower. V1 stated V13 is the only male CNA that works on R5's hallway. V1 stated V1 spoke with V13 who denied giving R5 a shower. V1 stated V1 spoke with R5 about the incident and R5 did not know what V1 was talking about. V1 stated V1 did not consider this to be an abuse allegation, therefore it was not reported to IDPH.The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents alleged abuse should be immediately reported to the facility's administrator, and if the matter involves alleged abuse or results in serious bodily injury, the administrator, or designee, shall submit an initial notice to the Illinois Department of Public Health (IDPH) no more than two hours after the matter becomes known. Event ID: Facility ID: 145441 If continuation sheet Page 2 of 4 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 07/22/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to protect from further abuse by staff following a staff to resident abuse allegation for 14 of 18 residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18) reviewed for abuse in the sample list of 18. R5's Nursing Note dated 07/18/2025 at 6:37 PM documents R5 reported to Certified Nursing Assistants (CNAs) that during his shower today a male CNA cleaned his perineal area a little hard and when R5 told the CNA it hurt, the CNA replied, it will heal. This note documents a CNA reported R5 was bleeding in scrotum area. R5's Nursing Note dated 07/18/2025 at 6:39 PM documents V10 Licensed Practical Nurse (LPN) assessed R5's scrotum which had a 2 centimeter (cm) by 1 cm open area, like skin was ripped, and blood noted in brief. This note documents R5 reported that he did not have a shower today but had one a couple days ago. V10 looked at the shower schedule and R5's showers are scheduled for Mondays and Thursdays. V10 obtained orders to apply barrier cream and Vitamin A & D ointment until healed. R5's Nursing Note dated 7/18/25 at 7:01 PM documents V1 Administrator returned call to the facility and was notified of R5's reported incident. R5's Nursing Note dated 07/18/2025 at 7:02 PM documents POA (Power of Attorney) was called about open area to scrotum and that due to the circumstance of how resident told how area got there will be investigated by administrator.On 7/22/25 at 11:30 AM V10 LPN was asked to describe any abuse allegations in the facility. V10 stated on 7/18/25 around 5:30 PM R5 had a bleeding scrotal skin tear and R5 reported to the CNAs that V13 CNA had given R5's shower that day and washed R5 hard, R5 told V13 to stop, and V13 said it will heal. V10 stated R5 had a 2 cm skin tear to his scrotum and R5 told V10 that it happened a few days prior. V10 stated V10 reported R5's allegation to V1 Administrator and R5's family immediately.On 7/22/25 at 12:36 PM V11 CNA stated on 7/18/25 around 5:30 PM V11 overheard R5 tell V15 CNA that V13 CNA gave R5 a shower on first shift, and V13 rubbed R5's scrotal area hard. V11 stated per R5, R5 told V13 to stop and V13 said it would be ok, it would heal. V11 stated the underside of R5's scrotum was bleeding and V10 was notified. V11 stated V11 considered this to be an abuse allegation and V10 reported the incident to V1.On 7/22/25 at 2:33 PM V15 CNA stated on the evening of 7/18/25 R5 told V15 that unidentified male CNA was rough with R5 during R5's shower. V15 stated R5 said R5 told the CNA to be more gentle and the CNA replied that he was just trying to get R5 clean. V15 stated there was blood in R5's brief and V15 reported this to the nurse.V13's Timecard dated 7/13/25-7/26/25 documents V13 worked on the following dates: 7/18/25 from 5:31 AM until 2:05 PM. 7/19/25 from 5:32 AM until 10:11 PM. 7/20/25 from 5:30 AM until 10:34 PM. The CNA Daily Assignment Sheets dated 7/19/25 and 7/20/25 document V13 worked on the Independence Place unit. The facility's Resident Bed List Report dated 7/22/25 documents R6-R18 reside on the Independence Place unit. On 7/22/25 at 2:48 PM V1 Administrator stated on the evening of 7/18/25 R5 reported to staff that during his shower V13 CNA scrubbed a little hard and that it hurt. V1 stated that was all that was reported to V1. V1 stated V1 looked at R5's shower documentation and V13 had not given R5 a shower. V1 stated V13 is the only male CNA that works on R5's hallway. V1 stated V1 spoke with V13 who denied giving R5 a shower. V1 stated V1 spoke with R5 about the incident and R5 did not know what V1 was talking about. V1 stated V6 CNA who said V7 CNA gave R5's shower that Friday, but V7 said V7 didn't give R5's shower. V1 stated 7/14/25 was R5's only documented shower, which was given by V21 CNA. V1 stated V1 did not consider this to be an abuse allegation, therefore it was not reported to IDPH. V1 stated no alleged perpetrator was identified. V1 confirmed V13 CNA, alleged perpetrator reported by R5, was not placed on suspension pending investigation of this allegation. On 7/22/25 at 3:19 PM V2 Director of Nursing confirmed the CNA Daily Assignment Sheets 7/19/25 and 7/20/25 accurately reflect the staff's hall assignments and V13 worked on the Independence Place unit. The facility's Abuse Prohibition and Reporting Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145441 If continuation sheet Page 3 of 4 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 07/22/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm policy dated 11/28/19 documents if the alleged abuse involves an employee as the perpetrator, then the administrator shall immediately suspend the suspected employee without pay pending the investigation of the incident. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145441 If continuation sheet Page 4 of 4