Shelbyville Manor

In the surveyor’s words

From the most serious findings on record at Shelbyville Manor, in the surveyor’s own words.

• Actual harm, isolatedF684May 7, 2026

  Based on observation, interview and record review, the facility failed to implement post fall interventions for one resident (R3) of four residents reviewed for falls on the sample list of four residents. R3's fall resulted in spinal fractures and a right ankle fracture which required R3 to wear a back brace, compression wrap to the ankle and a surgical shoe for non-surgical intervention to treat severe pain. R3 sustained severe pain when interventions were not implemented.Findings include:R3's Current admission Diagnoses Sheet dated 4/28/26 upon return from the hospital post-fall 4/16/26 documents the following: Age-Related Osteoporosis with Current Pathological Fracture, Vertebra (e), Subsequent Encounter for Fracture with Routine Healing (Primary), Low Back Pain, Unspecified… […]

• Actual harm, isolatedF689May 7, 2026

  Based on observation, interview and record review, the facility failed to maintain a safe environment, free of an accident hazard for one (R1) of four residents reviewed for falls on the sample list of four residents. R1's fall resulted in a hand laceration that required emergency medical treatment of 15 sutures to repair.Findings include:R1's most recent Diagnoses sheet documents the following: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Laceration of Superficial Palmar Arch of Right Hand, Initial Encounter.R1's most recent Minimum Data Set (MDS) documents the following: Brief Interview of Mental Status (BIMS) score of five out of a possible 15, indicating severe cognitive impairment.R1's same MDS… […]

• Actual harm, isolatedF604Oct 23, 2025

  Based on Observation, Interview, and Record Review the facility failed to identify full body pillows and a concave mattress as restraints, failed to assess the resident for the use of the full body pillows and concave mattress, and failed to ensure that the body pillows and concave mattress did not pose a risk of injury from falls for one (R1) of eight residents reviewed for restraints on the sample list of eight. This failure resulted in R1 who is at high risk for falls and has cognitive impairment climbing out of bed and falling on multiple occasions while the full body pillows where in place. […]

• Actual harm, isolatedF600May 2, 2025

  Based on observation, interview, and record review, the facility failed to prevent an incident of staff to resident physical and verbal abuse and failed to provide adequate supervision to prevent a resident-to-resident incident of physical abuse. This failure affects two residents (R76 and R62) out of four reviewed for abuse on the sample list of 35. This failure resulted in R62 suffering a high level of pain and a bump on the head. Findings include: 1. The facility's Initial Incident Report dated 3/21/25 documents an allegation reported from a family member (V23) that a Certified Nursing Assistant (V22) had used profanity towards a resident (R76) and then had put his hands on the shoulders of R76 to restrict and confine R76 to stay seated in the wheelchair. […]

• Actual harm, isolatedF689May 2, 2025

  Based on record review and interview, the facility failed to provide a cognitive impaired resident, who required substantial to maximum staff assistance, with a safe transfer and toileting. This failure resulted in R57 sustaining two fractures on 3/12/25, that required emergency medical attention and surgical repair. The facility also failed to initiate targeted post-fall interventions to address the root cause of self-toileting. These failures affected one of three residents (R57) reviewed for falls on the sample list of 35. Findings include: R57's Minimum Data Set, dated [DATE] documents R57's Brief Interview for Mental Status score was 12 out of a possible 15, indicating moderate cognitive impairment. […]