Willows of Shelbyville

In the surveyor’s words

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

• Actual harm, isolatedF740May 2, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2025

  Based 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. Findings include: A tour of the kitchen was conducted with the Dietary Manager (DM) on [DATE] at 10:35 a.m. Interviews were conducted with the DM at that time. During the tour, the DM indicated they did not have any test strips to test the stationary sanitization buckets used for wiping cloths. The DM indicated they could not test the solution for proper chemical levels. […]

• No harm, potential for more than minimal, widespreadF812Oct 1, 2024

  Based 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. Findings include: A tour of the kitchen was conducted with the DS (Dietary Supervisor) on 9/25/24 at 11:15 a.m. Interviews were conducted with the DS at that time. During the tour, an observation of the clean dish racks was made. The silverware was stored in a cylindrical container with the handles facing downward, instead of upward. During the tour, an observation of the dry storage room was made. […]

• No harm, potential for more than minimal, widespreadF921Oct 1, 2024

  Based 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. Findings include: A tour of the kitchen was conducted with the DS (Dietary Supervisor) on 9/25/24 at 11:15 a.m. Interviews were conducted with the DS at that time. The wall behind the ice chest was missing baseboard. There was a cracked wall corner cover by the handwashing sink. The dishwasher counter area had four missing tiles underneath it. There was one missing tile underneath the three-compartment sink. The dry storage room had a significant amount of dirt and debris, including macaroni, on the floor against the baseboards underneath the food storage racks. […]

• No harm, potential for more than minimal, patternF656Dec 23, 2025

  Based 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)Findings include:1. The clinical record for Resident 7 was reviewed on 12/19/25 at 11:14 a.m. The resident's diagnoses included, but were not limited to: osteoporosis, Alzheimer's disease, anxiety, chronic obstructive pulmonary disease, and chronic pain. The Interdisciplinary Team (IDT) note, dated 11/13/25, indicated the resident had an unwitnessed fall on 11/12/25 in the common area. She was found on the floor beside a recliner. The resident complained of pain to her left hip. […]