Inspection·May 3, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review the facility failed to thoroughly investigate, complete a root cause analysis, or initiate resident centered interventions for residents after falling. This failure affects two (R1, R2) of three residents reviewed for falls in a sample list of four. Findings Include: R1's diagnoses list printed 5/2/23 includes the following diagnoses: Heart Failure, Major Depression, anxiety disorder, Alzheimer's Disease, Dementia, Hemiplegia, and history of Cerebral Vascular Accident. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired and has a history of multiple falls. R1's Fall Risk assessment dated [DATE] documents R1 is at risk for falls. R1's fall investigation documentation dated 3/23/23 at 9:30AM and 4/2/23 at 4:38AM document R1 was found on the floor of her room after unwitnessed falls. No root cause analysis is documented for these falls. No updated resident centered fall interventions are included in R1's Care Plan following these falls. R1's fall investigation documentation dated 4/2/23 at 7:05AM documents R1 noted lying on left side on floor in room. Moderate amount of blood around (R1's) head. R1 was documented to have been sent to the hospital emergency room.R1's progress note dated 4/2/23 at 10:15AM documents (R1) returned from Emergency Room. Bruising to forehead and nose. Skin tear covered with Band-Aid. No root cause analysis is documented for this fall. No updated resident-centered fall interventions are included in R1's Care Plan following this fall. R1's fall investigation documentation dated 4/6/23 at 8:35AM documents R1 noted on left side lying on room floor. R1 alert and oriented x4. No new injuries noted. No root cause analysis is documented for this fall. No updated resident-centered fall interventions are included in R1's Care Plan following this fall. R2's diagnoses list printed 5/2/23 includes the following diagnoses: Heart Failure, Major Depression, anxiety. R2's Minimum Data Set (MDS) documents R2 is severely cognitively impaired. and at risk for falls. R2's fall investigation documentation dated 4/18/23 at 8:06AM documents R2 was standing at the front hall yelling and stated (R2) cannot walk any more. R2 backed up to the wall and grabbed the (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 3 Event ID: 145836 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 145836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shelbyville Healthcare & Senior Living 2116 South 3rd Dacey Drive 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)