Inspection·August 1, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide timely treatment of a resident's left lower back and left hip skin tears. The facility also failed to update the resident's skin care plan with the facility acquired skin tears. These failures affected one (R3) out of three residents reviewed for Accidents in a sample list of three residents. Findings include:R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 is dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R3's Skin Integrity Care plan initiated 2/17/25 does not include updated interventions for R3's Left Lower Back and Left Hip skin tears obtained at facility on 7/3/25. R3's Physician Order Set (POS) dated July 2025 documents a physician order starting 7/7/25 to monitor R3's Left Hip skin tear for decrease in size/severity and signs and symptoms (s/s) of infection (increased warmth, drainage, smell, decreased function) daily until healed. This same POS documents a physician order starting on 7/10/25 with no end date to apply Zinc cream every shift to R3's Left Hip skin tear. This same POS documents a physician order starting 7/7/25 and ending 7/10/25 to cleanse R3's Left Lower Back skin tear and cover with dry dressing daily and as needed. R3's Wound Assessment and Plan dated 7/3/25 documents R3's Left Lower Back skin tear as measuring 4.0 centimeters (cm) long by 4.0 cm wide by 0.1 cm deep with an onset date of 7/3/25. This same assessment documents R3's Left Hip skin tear as measuring 4.0 cm long by 1.6 cm wide by 0.1 cm deep with an onset date of 7/3/25. This same wound assessment documents physician orders to cleanse R3's Left Hip and Left Lower Back skin tears, cover with a dry dressing daily and as needed. R3's Treatment Administration Record (TAR) dated July 2025 documents R3's treatments for skin tears starting 7/7/25. There is no physician orders documented on R3's TAR prior to 7/7/25 for the treatment of R3's skin tears. On 8/1/25 at 12:15 PM V9 (Wound Nurse/Licensed Practical Nurse/LPN) stated R3 obtained his Left Lower Back and Left Hip skin tears at the facility. V9 stated she first noted R3's two skin tears on 7/3/25 when rounding with V10 (Wound Physician Assistant/PA). V9 stated she received orders for treatment on 7/3/25 but did not enter V10's verbal orders until 7/7/25 when she received V10's written orders. V9 (Wound Nurse/LPN) stated she should have entered R3's wound treatment orders on 7/3/25. V9 stated R3's two skin tears were caused by staff pulling on R3's incontinence brief or linens too hard when providing incontinence cares causing a shearing effect. V9 stated she should have completed an incident report or risk management but did not. V9 stated R3's care plan should have been updated with his two new facility acquired skin tears to help prevent further incidents. The facility policy titled Skin Condition Monitoring revised January 2018 documents upon notification of a skin lesion wound, or other skin abnormality, the nurse will assess and document the findings in the nurses' notes and complete the Quality Assurance (QA) form for Newly Acquired Skin Condition. The nurse will obtain a treatment order that includes the type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be Residents Affected - Few (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: 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 08/01/2025 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)