Willows of Shelbyville
2309 S Miller St., Shelbyville, IN 46176 · Shelby County · (317) 398-9781
121 certified beds, about 84 residents a day · Government - City/county · Medicare and Medicaid since 1967
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 155022 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on December 23, 2025, inspectors cited 4 health deficiencies (the Indiana average is 7.2, the national average 9.2).
Of 30 health citations since July 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.85 hours per resident per day, against 3.69 across Indiana and 3.86 nationally. Registered nurses accounted for 0.37 of those hours.
46.8% of nursing staff left within the year CMS measured (Indiana average 45.9%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1007/23
502/24
305/24
710/24
103/25
412/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
3E
3F
Potential for minimal harm
0A
0B
0C
December 23, 2025Standard inspection · 4 citations
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' fall interventions were in place for 3 of 4 residents reviewed for care plan implementation. (Residents 7, 19, and 44)
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident's nutritional supplement, as ordered, and have their family member complete weekly menus, as care planned. (Resident 9)
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a resident's plan of care to address her behavior of picking/scratching herself and adequately monitor this behavior for 1 of 5 residents reviewed for dementia care. (Resident 53)
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure indwelling urological devices were maintained in accordance with infection control measures for 3 of 3 residents reviewed for indwelling urological devices. (Resident 96, Resident 11, and Resident 6)
March 6, 2025Complaint inspection · 1 citation
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean manner and ensure a sanitizing bucket was at proper sanitization levels. This had the potential to affect 71 of 71 residents who reside in the facility.
October 1, 2024Standard inspection, Complaint inspection · 7 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store food and silverware properly and wear hair restraints in the kitchen. This had the potential to affect 57 of 57 residents in the facility.
- F Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a cleanly manner and in good repair for the potential to affect 57 of 57 residents in the facility.
- E Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to redirect residents with wandering behaviors from other residents' rooms resulting in a lack of privacy for other residents for 5 of 8 residents reviewed for dementia care. (Residents 4, 22, 24, 27, 41, 157, 159)
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review the facility failed to accurately document a resident's code status in the clinical record for 1 of 1 resident reviewed for advanced directives (Resident 40).
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to encode minimum data set (MDS) assessments accurately for 2 of 2 residents reviewed for MDS accuracy. (Resident 44 and Resident 53)
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review the facility failed to conduct care plan meetings for 1 of 4 residents reviewed for care plans. (Resident 10)
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure neurological checks, that included vital signs, were fully conducted for a resident who experienced an unwitnessed fall for 1 of 4 residents reviewed for accidents. (Resident B)
May 2, 2024Complaint inspection · 3 citations
- G Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's plan of care for behavioral health was implemented and evaluated after having physical behavioral symptoms directed towards staff and other residents, document a resident's behaviors in the clinical record, document interventions in response to such behaviors, document the reasoning for administration of an intramuscular (IM) injection of antianxiety and antipsychotic medications, and ensure other residents' safety was maintained during behavioral episodes to where a resident (Resident E) was found to have their hands around another resident (Resident F's) neck that resulted in redness. Resident F had felt fearful, anxious, and the need to relocate to another nursing facility.
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with dementia had a care plan with resident-specific interventions in regards to making inappropriate comments towards staff, monitoring of behaviors and documentation of such behaviors in the clinical record; document interventions in response to such behaviors, and ensure the safety of other residents to where a resident (Resident H) was found to have touched another resident's (Resident G's) breast for 3 out of 5 residents reviewed for behavioral health. (Resident G and Resident H and Resident J)
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic medication was administered per physician orders for 2 of 3 residents reviewed for medication administration. (Resident E and Resident D)
February 22, 2024Complaint inspection · 5 citations
- D Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's preference for frequency of bathing was honored on a regular basis for 1 of 4 residents reviewed for bathing. (Resident B)
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy supplies were maintained in a clean and hygienic manner for 1 of 3 residents reviewed for oxygen therapy services. (Resident F)
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 residents reviewed for pain medication received pain medications as ordered by their physician. (Resident B)
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an insulin pen was properly labeled for use for 1 of 4 residents observed during 1 of 2 medication pass observations with 3 staff members with 4 residents. (Resident H, LPN 3)
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff appropriately sanitized a glucometer (testing machine for blood sugar levels) utilized for multiple residents. (Resident H and QMA 2)
July 26, 2023Standard inspection · 10 citations
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure overhead light fixtures were free of dead insects for all 4 hallways in the facility. This had the potential to affect all 63 residents who resided in the facility.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dignified environment for 2 of 2 residents reviewed for dignity. (Resident C and Resident D)
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to provide beneficiary notices for 1 of 3 residents reviewed. (Resident 8)
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to file a grievance for a resident voicing missing items for 1 of 2 residents reviewed for missing personal property. (Resident 5)
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was initiated for the utilization of a splint for 1 of 1 resident reviewed for range of motion. (Resident 37)
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide supervision and/or assistance for 3 of 3 residents observed for eating activities of daily living. (Resident 61, Resident 31, and Resident 33).
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the utilization of a gait belt during a transfer for 1 of 1 resident randomly observed. (Resident 30)
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview and record review, the facility failed to document the outputs as careplanned for a resident with an indwelling urinary catheter for 1 of 1 residents reviewed for urinary catheters. (Resident 61)
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water pitchers were available for resident utilization for 2 of 3 residents reviewed for hydration. (Resident 52 and Resident D)
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed between contact with multiple residents during dining service. (Resident D and Resident 11)
Fire safety inspections
37 fire safety citations on file: 12 on December 23, 2025, 10 on October 1, 2024, 15 on July 26, 2023.
Every fire safety citation37 citations
- F Implement emergency and standby power systems.
- F Provide a written emergency evacuation plan.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Have properly located and lighted "Exit" signs.
- E Provide properly protected cooking facilities.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E Have properly installed electrical wiring and gas equipment.
- E Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E Have an externally vented heating system.
- E Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- C Conduct testing and exercise requirements.
- F Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E Have exits that are accessible at all times.
- E Have properly located and lighted "Exit" signs.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Provide properly protected cooking facilities.
- E Install an approved automatic sprinkler system.
- E Install corridor and hallway doors that block smoke.
- E Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E Ensure proper usage of power strips and extension cords.
- F Provide emergency officials' contact information.
- F Establish staff and initial training requirements.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Install an approved automatic sprinkler system.
- F Inspect, test, and maintain automatic sprinkler systems.
- E Meet other general requirements.
- E Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- E Install corridor and hallway doors that block smoke.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Have properly installed electrical wiring and gas equipment.
- E Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C Create arrangements with other facilities to receive patients.
- C List the names and contact information of those in the facility.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Indiana | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.85 | 3.69 | 3.86 |
| Registered nurses | 0.37 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.53 | 3.25 | 3.42 |
| Nurse aides | 2.50 | ||
| Licensed practical nurses | 0.98 | ||
| Nursing staff turnover (share who left in a year) | 46.8% | 45.9% | 45.8% |
| Registered nurse turnover | 44.4% | 40.3% | 42.9% |
| Administrators who left | 0 |
CMS expects 5.04 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.98 on weekdays and 3.53 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.77 in April to June 2025 to 3.85 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.85 | 0.37 | 3.98 | 3.53 | 4.7% | 0 of 90 | 84 |
| Oct to Dec 2025 | 4.01 | 0.42 | 4.20 | 3.52 | 7.8% | 0 of 92 | 80 |
| Jul to Sep 2025 | 3.77 | 0.46 | 4.00 | 3.18 | 3.4% | 0 of 92 | 76 |
| Apr to Jun 2025 | 3.77 | 0.46 | 4.06 | 3.04 | 1.1% | 0 of 91 | 72 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Indiana, Jan to Mar 2026 | 3.63 | 0.62 | 3.80 | 3.19 | 3.4% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Indiana | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.4 | 11.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.4 | 1.1 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 12.0 | 3.9 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 21.5 | 11.9 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.7 | 3.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 27.0 | 13.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 9.2 | 22.2 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 2.2 | 10.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.4 | 1.8 |
Owners and operators
Legal business name: MAJOR HOSPITAL.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Claxton, Ryan | Corporate officer | Individual | 03/27/2025 | |
| Horner, John | Corporate officer | Individual | 01/01/2012 | |
| Shelbyville in Opco LLC | Operational/managerial control | Organization | 07/01/2023 | |
| Claxton, Ryan | Operational/managerial control | Individual | 03/27/2025 | |
| Frankel, Israel | Operational/managerial control | Individual | 07/01/2023 | |
| Paul, Mandi | Operational/managerial control | Individual | 04/01/2024 | |
| Radadiya, Pragneshkumar | Operational/managerial control | Individual | 07/01/2023 | |
| Shelbyville in Opco LLC | Adp of the SNF | Organization | 07/02/2025 | |
| Claxton, Ryan | Adp of the SNF | Individual | 03/27/2025 | |
| Frankel, Israel | Adp of the SNF | Individual | 07/01/2023 | |
| Paul, Mandi | Adp of the SNF | Individual | 04/01/2024 | |
| Radadiya, Pragneshkumar | Adp of the SNF | Individual | 07/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 13 problems in this area, most recently on December 23, 2025: "Provide enough food/fluids to maintain a resident's health."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 5 problems in this area, most recently on October 1, 2024: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive."
- When is the care plan meeting, and can family attend it?Inspectors cited 4 problems in this area, most recently on December 23, 2025: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 3 problems in this area, most recently on December 23, 2025: "Provide and implement an infection prevention and control program."
Other nursing homes nearby
- Especially Kidz Health & Rehab Shelbyville, 0 mi · 3 of 5 stars · 20 citations
- Ashford Place Health Campus Shelbyville, 3.8 mi · 4 of 5 stars · 26 citations
- Waldron Rehabilitation and Healthcare Center Waldron, 7.1 mi · 3 of 5 stars · 41 citations
- Morristown Manor Morristown, 12.1 mi · 4 of 5 stars · 30 citations
- Homeview Center of Franklin Franklin, 13.9 mi · 5 of 5 stars · 5 citations
- Compass Park Franklin, 14 mi · 5 of 5 stars · 8 citations
- Hickory Creek at Franklin Franklin, 14.7 mi · 5 of 5 stars · 6 citations
- Otterbein Franklin Seniorlife Comm Res & Com Care Franklin, 15.3 mi · 3 of 5 stars · 17 citations
Indiana contacts for a concern about a nursing home
These are the official offices in Indiana. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Indiana Department of Health, Division of Long-Term Care, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Indiana Long-Term Care Ombudsman Program, 800-622-4484. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Indiana Department of Health, Nursing Home Report Cards, where Indiana publishes its own records on licensed homes.
Common questions
- What is Willows of Shelbyville's Medicare star rating?
- CMS rates Willows of Shelbyville 2 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Willows of Shelbyville get at its last inspection?
- 4 health deficiencies at the standard inspection on December 23, 2025. The Indiana average is 7.2.
- Has Willows of Shelbyville been fined?
- CMS lists no fines in the last three years.
- Does Willows of Shelbyville accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Willows of Shelbyville?
- CMS lists 12 owners and managers. Legal business name: MAJOR HOSPITAL.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.