Shelbyville Manor

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

61.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 165 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 96 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 109 beds and averages 85.1 residents a day — about 78% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.03 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.94 hrs/resident/day on weekends vs 4.42 on weekdays — 11% thinner on weekends. RN hours go from 0.56 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

43 citations, most serious first. The 16 most serious are shown; the remaining 27 are one tap away and print in full.

• Actual harm · G2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 (Admission), Wedge Compression Fracture of Fourth Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Long Term (current) use of Anticoagulants, Personal History of (healed) Osteoporosis Fracture, Chronic Atrial…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 documents R1 required partial/moderate staff assistance with the following: Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Toilet transfer: The ability to get…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-10-23 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. This failure ultimately resulted in R1 climbing out of bed and falling and sustaining a left pelvic fracture.Findings Include:On 10/21/2025 at 10: 55 AM, R1 was lying in bed on top of a concave mattress. Full-length body pillows were placed on top of the concave mattress and were positioned along both sides of R1's body underneath a fitted sheet. On 10/22/25 at 10:10 AM, R1 was lying in bed on top of a concave mattress.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-05-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. On 4/29/25 at 10:26 AM, R76, having severe cognitive impairment and Dementia, stated he had no recollection of the incident involving the allegations against V22. On 5/1/25 at 11:01 AM, V1, Administrator, confirmed there was an allegation against V22…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The same MDS inaccurately (according to V20, MDS/Care Plan Coordinator and V27, Nurse Practitioner below interviews) documents R57 had no falls prior to admission to the facility. R57's Face Sheet documents his admission date as 3/6/25. The same Face Sheet includes the following diagnoses: Dementia in Other…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to safely transport R1 after a shower to prevent a traumatic fall. This failure resulted in R1 falling from a shower chair to the floor causing multiple back and neck fractures requiring emergency medical evaluation and treatment at two hospitals. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list (9/25/2024) documents R1's diagnoses include Spastic Paraplegia (inherited neurological disorder causing muscle weakness and difficulty or inability to walk), Abnormal Posture, Difficulty in Walking, and Muscle Wasting and Atrophy. R1's quarterly assessment (7/24/2024) documents R1 has upper and lower extremity impairment limiting range of motion, is completely dependent on staff for all activities of daily living and utilizes a wheelchair for locomotion. The same record documents R1 is dependent on staff assistance for mobility while using a wheelchair. The facility incident report (9/13/2024) documents on 9/13/2024 at 8:50AM, facility staff were moving R1 on a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-05 · tag F0744 — failed to care for residents with dementia — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate treatments, services, non-pharmalogical interventions, and abuse risk assessments to maintain psychosocial well-being for residents diagnosed with dementia and severe cognitive impairment. This failure affects four residents (R2, R3, R4, R5) out of four reviewed for resident-to-resident incidents on the sample list of fourteen.Findings include:R2's Demographic Face Sheet dated 2/27/26 documents R2 was admitted to the facility 6/20/24 with medical diagnoses including Dementia. R2's Minimum Data Set, dated [DATE] documents R2 could not answer any questions during a Brief Interview for Mental Status and was assessed by staff as severely cognitively impaired.R3's Minimum Data Set, dated [DATE] documents R3 completed the Brief Interview for Mental Status with a score of 4 out of a possible 15, rating R3 as severely cognitively impaired.R4's Demographic Face Sheet dated 2/27/26 documents R4 was admitted to the facility 7/3/25…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to provide showers, twice a week, to a dependent resident. This failure affected one of three residents (R7) reviewed for showers on the sample list of 14. Findings include:R7's Current Diagnoses List documents R7 has diagnose of Chronic Kidney Disease, Diabetes, Chronic Pain, and Morbid Obesity,R7's Minimum Data Set, dated [DATE] documents the following: Brief Interview of Mental Status score of 14 out of a possible 15, indicating no cognitive impairment.R7's Care Plan dated 2/19/26 documents the following: Approach Start Date: 03/14/2025, Bathing Type: (R7) receives showers twice weekly. (R7) requests we (facility staff) make sure she is dry and pat skin folds dry.R7's February 2026 shower sheets document R7 received a shower on 2/3/26, 2/10/26, 2/18/26, and 2/21/26. There is no documentation that R7 declined a shower between 2/3/26 and 2/10/26 or between 2/10/26 and 2/18/26 which indicates R7 missed two showers.On 2/24/26 at 1:10 pm R7 stated the staff…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to implement fall prevention interventions according to residents' care plans for fall risks. This failure affects two residents (R6 and R10) out of three reviewed for falls with injuries on the sample list of fourteen.Findings include:1. R10's Demographic Face Sheet dated 3/3/26 documents R10 was admitted to the facility 4/10/25 with medical diagnoses including Dementia with Behavior Disturbance, Neuralgia, Glaucoma, History of Transient Ischemic Attacks, Chronic Pain, Pseudobulbar Affect, rash, Insomnia, Depression, Migraines, and Vitamin Deficiency.R10's Physician Order Sheet dated 3/3/26 documents R10 receives multiple anti-hypertension, anti-depressant, anti-anxiety, and anti-convulsant medications.R10's Event charting with associated Nursing Progress Notes dated 4/19/25 document R10 slid out of her bed onto the floor.R10's Event charting with associated Nursing Progress Notes dated 6/6/25 documents R10 was self-propelling her wheelchair, got her feet tangled in the wheelchair foot pedals, fell out of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0808 — failed to follow doctor-ordered diets — isolated
  Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a physician ordered high protein supplement and failed to honor a resident's food preference. These failures affect one of three residents (R8) reviewed for dietary intake/meals on the sample list of 14.Findings include:R8's Current Diagnose List includes: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Vitamin D Deficiency, Unspecified, Vitamin E Deficiency, Unspecified, and Ascorbic Acid Deficiency and Disorder of Teeth and Supporting Structures, Unspecified.R8's Dietary Physician Order dated February 04, 2026, documents R8 is to have a Regular HP (High Protein) supplement TID (three times a day) with meals. 07:30 AM, 12:00 PM, and 05:30 PM.R8's Minimum Data Set, dated [DATE] documents the following: R8's Brief Interview of Mental Status score as 11 out of a possible 15 indicating, moderate cognitive impairment.On 2/24/26 at 12:20 pm R8 was served…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to update one (R1) resident care plan with fall interventions, repeatedly failed to implement fall interventions and complete thorough fall investigations for two (R1, R2) residents out of three residents reviewed for accidents in a sample list of eight residents.Findings include: 1.R1's undated Face Sheet documents medical diagnoses as Dementia, Psychotic Disturbance, Diabetes Mellitus Type II, History of Urinary Tract Infection (UTI), Vitamin B deficiency, Pain and Vitamin D deficiency. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R1's Fall Risk Evaluation dated 10/7/25 documents R1 as a high fall risk. R1's Nurse Progress Note dated 9/29/25 at 7:15 AM, documents R1 had an unwitnessed fall in her room just outside the bathroom. This same note…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-11-16 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure hot water heaters housed in resident closets are sanitary for six (R1, R4, R5, R6, R7, R8) residents out of six residents reviewed for Physical Environment in a sample list of eight residents. Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R1's Electronic Medical Record (EMR) does not include V6 (R1's) Power of Attorney (POA) concern of R1's hot water heater in R1's closet having 'mold, lime build up and rust'. On 11/15/25 at 1:20 PM, R4 and R5's shared closet housed a ten-gallon hot water heater. This water heater had a bright green and white dry substance covering the front quarter of the water heater, approximately six inches off the closet floor underneath and approximately eight to ten inches of the pipes attached to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-22 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to protect from further abuse by staff following a staff to resident abuse allegation for 14 of 18 residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18) reviewed for abuse in the sample list of 18. R5's Nursing Note dated 07/18/2025 at 6:37 PM documents R5 reported to Certified Nursing Assistants (CNAs) that during his shower today a male CNA cleaned his perineal area a little hard and when R5 told the CNA it hurt, the CNA replied, it will heal. This note documents a CNA reported R5 was bleeding in scrotum area. R5's Nursing Note dated 07/18/2025 at 6:39 PM documents V10 Licensed Practical Nurse (LPN) assessed R5's scrotum which had a 2 centimeter (cm) by 1 cm open area, like skin was ripped, and blood noted in brief. This note documents R5 reported that he did not have a shower today but had one a couple days ago. V10 looked at the shower schedule and R5's showers are scheduled for Mondays and Thursdays. V10 obtained orders to apply barrier cream and Vitamin A & D ointment until healed. R5's Nursing Note…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-22 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report allegations of staff to resident physical abuse to the state survey agency for two of 18 residents (R1, R5) reviewed for abuse in the sample list of 18.1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment.R1's Nursing Note dated 7/21/2025 at 5:10 PM documents V16 (R1's Family) spoke to V9 Licensed Practical Nurse (LPN) about incident and R1 experienced pain during repositioning. V16 was dissatisfied with the incident and stated V16 just wanted R1 safe. R1's Nursing Note dated 7/21/2025 at 5:20 PM documents V1 was notified of the incident, and Certified Nursing Assistant (CNA) was sent home until further investigation. R1's Nursing Note dated 7/21/25 at 5:25 PM documents Nurse Practitioner was notified of incident and increased right hip pain, and orders received to send R1 to the emergency room for further evaluation and right hip x-ray.R1's emergency room Note dated 7/21/25 at 7:07 PM documents R1 had a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-02 · tag F0640 — pattern
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit (submit) Minimum Data Set Resident Assessment Instruments to the Centers for Medicare and Medicaid within the required time frames. This failure affects five residents (R18, R49, R52, R54, and R58) out of five reviewed for Minimum Data Set transmission on the sample list of 35. Findings include: 1. R58's Minimum Data Set (MDS) dated with an Assessment Reference Date (ARD) of 2/21/25 was documented on the facility's CMS (Centers for Medicare and Medicaid) Submission Report dated 4/29/25, documenting R58's MDS was submitted on 4/29/25. 2. R52's MDS dated with an ARD of 2/4/25 was documented on the facility's CMS Submission Report dated 4/29/25, documenting R52's MDS was submitted on 4/29/25. 3. R49's MDS dated with an ARD of 2/18/25 was documented on the facility's CMS Submission Report dated 4/23/25, documenting R49's MDS was submitted 4/23/25. 4. R18's MDS dated with an ARD of 2/18/25 was documented on the facility's CMS Submission Report…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-02 · tag F0644 — pattern
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a Level 2 Pre-admission Screening and Record Review (PASRR) for four (R12, R26, R45, R68) residents out of six reviewed for PASRR in a sample list of 35. Findings include: 1. R68's undated Face Sheet documents R68 admitted to the facility on [DATE]. R68's Pre-admission Screening and Record Review (PASRR) dated 1/26/24 documents R68 did not require a Level 2 PASRR. R68's Face Sheet documents R68 was diagnosed with Schizoaffective Disorder, Bipolar type on 10/16/2024. The facility was unable to provide documentation of a Level 2 PASRR being completed after R68 was diagnosed with a new mental health disorder on 10/16/2024. On 4/30/25 at 3:00 PM V19 Business Office Manager (BOM) stated the facility did not complete a Level 2 PASRR for R68. V19 stated V19 was under the impression after admission a Level 2 PASRR would only be completed if the resident had a significant change. On 5/2/25 at 9:00 AM V1 Administrator stated the facility had only been…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$77,985 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $28,985 — penalty dated 2026-05-07
• $49,000 — penalty dated 2025-10-23
• Medicare payment denial — starting 2025-05-31 for 13 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to UNLIMITED DEVELOPMENT, INC. — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $463K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL