Shelbyville Healthcare & Senior Living

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from misappropriation of property by a staff member for 21 of 21 residents (R1-R21) reviewed for misappropriation in the sample list of 21. This failure resulted in $12,091.78 being misappropriated from R1 through R21's pooled resident trust fund. All 21 residents affected are vulnerable with Dementia and/or Mental Illness/Disability diagnoses. A reasonable person would likely suffer psychosocial harm, such as emotional distress and lack of trust as a result of misappropriation of funds. The Past Noncompliance occurred from 9/30/25 to 4/29/26. The Findings Include:The Immediate Jeopardy began on 9/30/25 when V4 (Business Office Manager) began writing checks for cash without resident approval. V1 (Administrator) was notified of the Immediate Jeopardy on 5/6/26 at 2:40PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Narcotic medications are kept under a double lock system, failed to ensure medications are stored properly and failed to ensure medications remain in a locked environment. These failures have the potential to affect all 38 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 38 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to track and monitor employee illnesses. This failure had the potential to affect all 38 residents that reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to offer the staff COVID vaccinations and document the staff's COVID vaccination status. This failure has the potential to affect all 38 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level I for two of two residents (R6, R13) reviewed for PASRR's in a sample list of 29 residents. Findings Include: 1. R13's Medical Diagnoses List dated February 2026 documents R13 was admitted to the facility on [DATE] and had a new diagnosis of Major Depression added in November 2025. R13's Preadmission Screening and Resident Review (PASARR) Level II screening dated 12/13/24 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition (Serious Mental Illness) however, if changes occur or new information refutes those findings the facility must submit a new Level I screening. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene and sanitize a needleless access device prior to flushing a peripheral inserted central catheter for one of one resident (R53) reviewed for infection control on the sample list of 45 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a minimum of 80 square feet of floor space per resident bed. This failure affects 33 residents (R2-R6, R8, R10, R13-R20, R22-R30, R32-R35, R37, R38, R40, R49 and R50) out of 45 residents in the sample list.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects four of four residents (R1, R2, R3, R4) reviewed for abuse in a sample list of four residents.

Inspectors wroteDeficiencies at this level require more than one deficiency practice statement. A. Based on interview and record review the facility failed to transcribe and implement physician ordered wound treatments, failed to ensure wound supplies were provided and treatments were completed as ordered. The facility failed to accommodate a request for physician ordered wound treatments to be supplied or changed to an alternative treatment. The facility also failed to notify the provider of the facility changing the dressing orders, not transcribing/implementing Wound Physician Assistant (PA) orders, and not notifying the Wound PA of a resident request to change wound dressing orders for one (R1) resident out of five residents reviewed for wound care in a sample list of five residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a Full Time Director of Nurses (DON). This failure has the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate Enhanced Barrier Precautions (EBP) for four residents (R2, R3, R4, R5) out of five residents reviewed for EBP in a sample list of five residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the dignity of one (R1) resident out of five residents reviewed for resident rights in a sample list of five residents.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were treated with dignity for two (R2, R3) residents out of three residents reviewed for abuse in a sample list of six residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the safety of one (R1) resident from physical abuse by a staff member out of three residents reviewed for abuse in a sample list of six residents.

Inspectors wroteBased on interview and record review the facility failed to report a concern voiced in Resident Council Meeting of a staff members poor demeanor towards two (R2, R3) residents out of three residents reviewed for abuse in a sample list of six residents.

Inspectors wroteBased on interview and record review the facility failed to provide Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 10 days in a total of 39 days reviewed. This failure affects 25 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to formulate advanced directives. This failure affects one resident (R179) out of 16 reviewed for advanced directives on the sample list of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote resident's right to a safe, comfortable homelike environment. This failure affects one of two residents (R14) reviewed for the environment on the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure R14's Bilevel positive airway pressure (Bi-PAP) mask was replaced in a timely manner which resulted in facial skin breakdown. This failure affected one of one resident (R14) reviewed for the respiratory medical equipment on the sample list of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to implement a resident's departure alert system safety bracelet intervention, for twelve days after a resident's elopement. This failure affects one of four residents (R129) reviewed for incident /accidents on the sample list of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to implement timely infection control precautions for a resident positive with bacteria in the urine, provide Personal Protective Equipment (PPE) to ensure effective infection control when caring for residents, provide designated trash receptacles in resident room, ensure staff wore appropriate PPE during direct care, and implement a room change for a resident to prevent potential cross contamination. These repeated failures were ongoing 08/04/24-08/06/24. These failures affected two of two residents (R7 and R19) reviewed for infection control on the sample list of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet of floor space per resident bed. This failure affects 23 residents (R1 through R11, R13, R14, R17 through R24, R26, and R179) on the sample list of 28.

Inspectors wroteBased on interview and record review the facility failed to provide a Registered Nurse (RN) at least eight consecutive hours a day. This failure has the potential to affect all 24 residents residing in facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide rehabilitation services to four (R1, R2, R3, R4) residents out of four residents reviewed for Rehabilitation Services in a sample list of four residents.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a Registered Nurse for eight consecutive hours seven days a week for 11 of 14 days reviewed. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: The facility's Nurse Staffing policy with a review date of 12/7/17 documents, It is the policy of (the facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical, physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and the Director of Nursing as specified by the Illinois Department of Public Health. On 7/16/23 at 7:55 AM, V4 (Licensed Practical Nurse/LPN) stated that V4 was the only nurse working in the building at that time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination during meal service in a sample list of 34 residents. This failure has the potential to affect all 34 residents residing in facility.

Inspectors wroteBased on interview and record review the facility failed to have the required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential to affect all 34 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide bedrooms that measure at least 80 square feet per resident bed. This failure affects 34 out of 34 residents all of whom occupy Medicare or Medicaid certified beds in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to have comprehensive care plans for four of twelve residents (R5, R8, R15, R19) reviewed for care plans in the sample list of 23.

Inspectors wroteBased on interview and record review the facility failed to complete psychotropic medication assessments, implement/evaluate resident centered interventions, and identify and track targeted behaviors for four of six residents (R19, R12, R9 and R18) reviewed for psychotropic medications in a sample list of 23 residents.

Inspectors wroteBased on interview and record review the facility failed to complete Psychotropic Medication consent forms for three (R9, R18, R33) out of five residents reviewed for unnecessary medications in a sample list of 23 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to implement resident centered fall interventions and failed to completely investigate falls/determine root cause for one of five residents (R5) reviewed for falls in a sample list of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer oxygen at the correct setting for one of two residents (R8) reviewed for oxygen administration in the sample list of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination during pressure ulcer dressing change for one (R186) resident of two residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one of two (R19) residents reviewed for Antibiotic Stewardship in a sample list of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to post daily Nurse staffing. This failure has the potential to affect all 34 residents residing in facility.