Health inspection·November 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that intervention should be put into place immediately, reviewed in morning meeting and either placed on the resident care plan then or changed to a more appropriate intervention. V7 CPC stated R1 had multiple falls with interventions added into the care plan for ‘most'. V7 CPC stated she could not find an intervention for R1's 9/16/25 or 10/7/25 fall. On 11/15/25 at 3:30 PM, V14 Assistant Director of Nurses (ADON)/Registered Nurse (RN) stated all fall investigations should include basic information of who the resident/staff were that were involved, how the fall happened, what time it happened, if there were injured, what were the surroundings like, what care plan interventions were put into place and any other pertinent information relating to the resident's fall. V14 ADON stated a new intervention is supposed to be entered into the resident's care plan directly after a fall. V14 ADON confirmed R1 did not have fall interventions for R1's 9/16/15 and 10/7/25 falls. V14 ADON stated the fall intervention is put into place to help reduce the risk of the resident from falling again the same way. V14 ADON stated if the interventions are not implemented then the resident could fall again and ‘maybe get injured'. 2. R2's undated Face Sheet documents R2's medical diagnoses as Encephalopathy, Dementia, Anxiety, Muscle Wasting and Atrophy, Repeated Falls, Vitamin Deficiency, and difficulty in walking.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires maximum assistance from staff with oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R2's Care Plan intervention dated both 6/4/25 and 10/1/25 documents an intervention of 'alternative call light'. R2's Nurse Progress Note dated 10/13/25 at 6:24 AM documents R2 had an unwitnessed fall in her room. R2 was observed on the floor on her back between the bed and the wall. This same note documents R2 has been noted in her bed about 15 minutes before dayshift came on. On 11/15/25 at 1:05 PM, R2 was not in her room. V8 CNA stated 'alternate call light' means the resident should be visualized every 15 minutes. V8 CNA stated staff do not document this. V8 CNA stated there is no place in the CNA charting to document any resident's 15- minute checks. V8 Certified Nurse Aide (CNA) stated R2 was provided incontinence care at 11:30 AM, then R2 went to lunch. V8 CNA stated I guess (R2) is still up by the front nurses station. Lunch gets over at 12:30 PM so (R2) must be up there. The last time I saw (R2) was 11:30 AM. On 11/15/25 at 1:08 PM, V9 Certified Nurse Aide (CNA) stated the R2 normally eats lunch in the main dining room at 12:00 PM, then sits up front by the nurse's station. V9 CNA stated R2 'should be' monitored by the staff up front. V9 CNA stated she cannot verify that R2 has been monitored every 15 minutes. V9 CNA stated the last time she visualized R1 was before lunch. On 11/16/25 at 3:00 PM V12 Licensed Practical Nurse (LPN) stated R2 has an 'alternate call light' which means R2 should be visualized every 15 minutes. V12 LPN stated she arrived at 5:30 AM on 10/13/25. V12 LPN stated she was informed that R2 had fallen in her room ‘around 6:20 AM'. V12 LPN stated she remembered the dayshift staff had not been on R2's hall yet that morning due to they (staff) started getting people up on another hall first. V12 LPN stated the last time R2 was visualized was on night shift prior to 5:30 AM. V12 LPN stated she talked to the staff that morning after R2 fell, and they confirmed R2 had not been visualized yet that morning. V12 LPN stated she wrote in the nurse progress note that R2 had been visualized 'about 15 minutes' prior to her fall but that was incorrect information. V12 LPN stated no one asked her about the fall details. V12 LPN stated If someone would have asked, I would have realized right then that (R2) had not been seen since around 5:15 AM. We (staff) are supposed to be checking on our people (residents). This is what happens when we don't. On 11/16/25 at 2:00 PM, V2 Director of Nurses (DON) stated the facility will use ‘alternate call light' for a care plan intervention. V2 DON stated this means that a resident is supposed to be visualized every 15 minutes. V2 DON stated there is no documentation for any resident's 15-minute checks. V2 DON stated since the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145441 If continuation sheet Page 2 of 5 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 11/16/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete facility does not document the resident's 15-minute checks that would mean the facility cannot prove that any of those residents' interventions were in place prior to any fall. V2 DON stated the facility is going to ‘look at this system' to see how that can be rectified. V2 DON stated she has witnessed the staff caring for residents who have an alternate call light system but cannot say that the 15-minute check was completed every time due to lack of documentation. On 11/16/25 at 2:30 PM, V1 Administrator stated the facility does not keep separate files for fall investigations. V1 stated the only time a paper component would be available would be for a resident's fall that had to be reported to the State Agency. V1 Administrator stated whatever is in the Electronic Medical Record (EMR) is all that the facility would be able to provide. V1 Administrator stated the facility does not have a policy on staff documenting cares. V1 Administrator stated the expectation is for the staff to follow the care plan for each resident. The facility policy titled Call System (Alternate) revised April 2021 documents all residents that are unable to use a call light system will be provided with an alternate source of monitoring for needed assistance. Event ID: Facility ID: 145441 If continuation sheet Page 3 of 5 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 11/16/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure hot water heaters housed in resident closets are sanitary for six (R1, R4, R5, R6, R7, R8) residents out of six residents reviewed for Physical Environment in a sample list of eight residents. Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R1's Electronic Medical Record (EMR) does not include V6 (R1's) Power of Attorney (POA) concern of R1's hot water heater in R1's closet having 'mold, lime build up and rust'. On 11/15/25 at 1:20 PM, R4 and R5's shared closet housed a ten-gallon hot water heater. This water heater had a bright green and white dry substance covering the front quarter of the water heater, approximately six inches off the closet floor underneath and approximately eight to ten inches of the pipes attached to the water heater leading to the wall. The closet floor close to the perimeter of the water heater had a brown substance appearing to be rust. The wall behind the water heater on both sides had approximately three inches of black dots, some faded and some had clear edges appearing to be black mold. On 11/16/25 from 11:15 AM-11:30 AM, V2 Director of Nurses (DON) toured rooms with hot water heaters in the closets. V2 DON stated there are five rooms with hot water heaters in their closets. V2 DON stated four of the five rooms are occupied with residents. R4 and R5's shared closet housed a water heater that showed bright green and white dry substance that appeared as lime build up, rust and black dots on the wall that appeared as black mold. R6 and R7's hot water heater located in their shared closet showed a large area of brown flaky substance on the floor that appeared as rust. R8's water heater located in the closet showed bright green and white dry substance appearing as lime build up on the floor, the water heater and the pipes attached to the water heater. On 11/15/25 at 10:10 AM, V6 (R1) family stated R1 had a hot water heater in her closet that sat directly beneath her clothes causing her clothes to be 'very warm'. V6 stated the front of R1's hot water heater is 'a lot of lime build up' and on the back wall behind the water heater is 'mold all over the wall'. V6 stated she reported this to V7 Care Plan Coordinator during R1's last care plan meeting. V6 stated the facility did not 'fix the problem'. V6 stated having a hot water heater causes R1's clothes to be very warm and having 'mold and lime buildup' would be a health risk for any resident.On 11/15/25 at 1:25 PM, R4 stated the water heater ‘has been like that' since she admitted to the facility. R4 stated the water heater is on her roommate's (R5) side of the closet but R4 backs into ‘that thing' every time she gets into her closet. On 11/15/25 at 1:30 PM, R5 stated her clothes hang directly over the water heater. R5 stated she had a long robe hanging up in her closet that rested on top the water heater. R5 stated she reached in for her robe. R5 stated her robe was so hot she thought it would ‘catch fire'. R5 stated she reported this to the facility last week and V16 Maintenance Director told her it would get fixed. R5 stated With all of that mold, rust and lime build up I worry that we (R4, R5) will get sick. On 11/15/25 at 1:35 PM, V15 Custodian stated there are several rooms with water heaters located in the resident closets. V15 stated (R4, R5)'s water heater is in ‘the worst shape'. V15 stated the facility is working on getting that one fixed first. On 11/15/25 at 1:40 PM, V16 Maintenance Director stated he has been working with ‘corporate' to get the closet water heaters replaced. V16 stated he was aware of the ‘mold, rust and lime build up on a few' of the closet water heaters. V16 stated resident clothes do hang over the water heaters but should not be touching them. V16 stated the water heaters will not get hot enough to be a fire hazard but the ‘lime, rust and mold could make people sick'. V16 Maintenance Director stated the water heaters that could be a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145441 If continuation sheet Page 4 of 5 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 11/16/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete risk to the residents are being replaced first. On 11/16/25 at 11:10 AM, V7 CPC stated V6 (R1) Power of Attorney (POA) called V7 to inquire about a water heater in R1's room having 'mold, rust and a bunch of stuff' all over it. V7 CPC stated she reported this to V1 Administrator in the next day's morning meeting. V7 CPC stated I don't know whatever was done with that, but I reported it to (V1). That was (V1's) responsibility then, not mine. V7 CPC stated there was no progress note made about this concern. V7 CPC stated she did not remember what date V6 called her. On 11/16/25 at 2:30 PM, V1 Administrator stated the facility has ‘several' hot water heaters that are located in closets in resident rooms on three different hallways. V1 stated she was ‘just made aware' that three of those water heaters had ‘mold, mildew and rust' on them that could cause a potential health risk to a resident. V1 Administrator stated the water heaters ‘probably' don't get hot enough to cause a fire hazard but also should not have ‘mold, mildew and rust' on them within the resident areas. V1 Administrator stated V16 Maintenance Director is working to get them replaced. Event ID: Facility ID: 145441 If continuation sheet Page 5 of 5