Health inspection·October 23, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review the facility failed to identify full body pillows and a concave mattress as restraints, failed to assess the resident for the use of the full body pillows and concave mattress, and failed to ensure that the body pillows and concave mattress did not pose a risk of injury from falls for one (R1) of eight residents reviewed for restraints on the sample list of eight. This failure resulted in R1 who is at high risk for falls and has cognitive impairment climbing out of bed and falling on multiple occasions while the full body pillows where in place. This failure ultimately resulted in R1 climbing out of bed and falling and sustaining a left pelvic fracture.Findings Include:On 10/21/2025 at 10: 55 AM, R1 was lying in bed on top of a concave mattress. Full-length body pillows were placed on top of the concave mattress and were positioned along both sides of R1's body underneath a fitted sheet. On 10/22/25 at 10:10 AM, R1 was lying in bed on top of a concave mattress. Full-length body pillows were placed on top of the concave mattress and were positioned along both sides of R1's body underneath a fitted sheet.R1's Progress Note dated 7/20/25 documents R1 has Increased restlessness and anxiety this noc (night). Res (Resident) has exited bed and ambulated into hall multiple times this noc. Bed in lowest position, call light is within reach but not activated. Floor mats in place next to bed and body pillows in place beside resident in bed. Res gait and balance unsteady, Res frequently asking questions like Where am I supposed to be? What am I supposed to do? Where are my morn (mom) and dad?. Each time resident easily redirected, toilet offered, fluids offered and accepted, then res assisted back to bed. Res denies pain or discomfort. Res has not been incontinent of B/B (bowel/bladder). PRN (as needed) Ativan administered earlier in shift and somewhat but temporarily effective. R1's Minimum Data Set assessment dated [DATE] documents R1 is cognitively impaired and has a history of falls. R1's Post Fall Interdisciplinary notes document R1 was found on the floor at the end of her bed on 8/18/25 and 9/26/25. R1's care plan documents a fall intervention for a concave mattress on 8/18/25. R1's medical record does not contain an assessment for the use of the concave mattress or full-length body pillows. R1's Post Fall Interdisciplinary Notes document on 10/10/25 at 9:35 PM, R1 was observed sitting at the foot of her bed; (on the floor) on her buttocks with legs outstretched in front of her after attempting to self-transfer. This note documents the full body pillows were in place. This note documents R1 was sent to the hospital on [DATE] after complaining of pain. This note documents R1 was found to have a Left Superior Pubic Rami Fracture (pelvic fracture). This note does not document an assessment or reassessment for the use for the concave mattress or the body pillows. On 10/21/2025 at 11:35 PM, V4 Certified Nursing Assistant (CNA) stated she takes care of R1. V4 stated the body pillows are used so R1 doesn't get out of bed. V4 stated R1 can put her legs over the body pillows if R1 is determined to get out of bed. V4 stated that R1 can ambulate with assistance and has had body pillows since V4 has been taking care of R1 since April 2025. On 10/21/2025 at 11:40 AM, V5 CNA stated she has taken care of R1 since April Residents Affected - Few Page 1 of 2 145441 145441 10/23/2025 Shelbyville Manor 1111 West North 12th Street Shelbyville, IL 62565

F 0604 Level of Harm - Actual harm Residents Affected - Few 2025. V5 stated R1 has always had body pillows in place while in bed and if R1 is not in bed, R1 is to be up at the nursing station for closer supervision. V5 stated, R1 transfers with one assist. V5 stated R1 requires frequent visual checks because R1 likes to get out of bed and ambulate throughout the day and night. V5 stated R1 falls frequently because she is unsteady and requires assistance with walking. V5 stated that body pillows are to be placed under the sheet to keep R1 from getting up and walking by herself. When asked about R1's care plan, V5 looked at R1's electronic health record and stated R1's care plan does not include the use of the body pillow. V5 also stated R1's record did not contain an assessment for the use of the body pillows on R1's bed. On 10/21/2025 at 11:17AM V7 Licensed Practical Nurse (LPN) stated, R1 likes to get up by herself and the body pillows that are on each side of the bed are to prevent falls. V7 stated there is no assessment for the body pillows in the chart or care plan but staff were told by the facility to keep the body pillows on while R1 was in bed.On 10/21/2025 at 12:30PM, V11 Registered Nurse stated, If (R1) is determined she will find a way out of her bed as she is a high-risk faller.On 10/21/2025 at 12:56 PM, V2 Director of Nursing stated the body pillows are used to prevent R1 from getting out of the bed. V2 stated a restraint assessment should have been completed for the use of the body pillows and reassessed after each fall. At that time, V2 looked at R1's electronic medical record and confirmed there were no restraint assessments in the medical record and no interventions on the care plan related to the use of the full-length body pillows. V2 stated that the fracture was related to the fall on 10/10/25 and the body pillows were in place on R1's bed before the fall. On 10/21/2025 at 12:45 PM, V8 (R1's Hospice Nurse Practitioner) stated using the full body pillows on top of a concave mattress puts R1 at a greater risk for injury as it creates an extra obstacle for R1 to get out of bed. V8 stated R1 is at greater risk for falls and injury due to cognitive impairment, ambulatory, and receiving pain medication. The Facility's Restraint Policy with a revision date of 11/2017 documents restraints will not be used to restrict a resident's freedom of movement. This policy documents using a concave mattress to prevent a resident from getting out of bed as an example of a physical restraint. This policy documents that an assessment will be completed prior to the use of the restraint, and a reassessment will be completed every 90 days. The facility will assess for restraints with each resident to attain or maintain his/her highest practicable well-being in the least restrictive environment while preventing injury. 145441 Page 2 of 2