15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Shelbyville, IL
2-star overall rating with 2-star inspections with abuse icon flag with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1111 West North 12th Street, Shelbyville, IL
(217) 774-2111
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
109
Certified beds
Average residents
86
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Unlimited Development, Inc.
Operator or chain grouping
Approved since
1982-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.58
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.01
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
1,632
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0101
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.83
Baseline 17.60% · Performance 19.19% · Measure score 4.83 · Achievement 4.83 · Improvement 0
Healthcare-associated infections
6.04
Baseline 6.18% · Performance 6.03% · Measure score 6.04 · Achievement 6.04 · Improvement 0.80
Total nurse turnover
6.94
Baseline 29.03% · Performance 35.29% · Measure score 6.94 · Achievement 6.94 · Improvement 0
Adjusted total nurse staffing
4.25
Baseline 3.72 hours · Performance 4.29 hours · Measure score 4.25 · Achievement 4.25 · Improvement 2.25
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.84% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 212 · Observed rate 15.09% · Lower 95% interval 9.89% |
| Discharge to community | 61.09% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 165 · Observed rate 55.76% · Lower 95% interval 54.57% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.79% |
95.27%
0.5 pts better
|
Numerator 91 · Denominator 95 |
| Falls with major injury | 4.21% |
0.77%
3.4 pts worse
|
Numerator 4 · Denominator 95 |
| Discharge self-care score | 61.45% |
53.69%
7.8 pts better
|
Numerator 51 · Denominator 83 |
| Discharge mobility score | 66.27% |
50.94%
15.3 pts better
|
Numerator 55 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 6.32% |
2.29%
4 pts worse
|
Numerator 6 · Denominator 95 · Adjusted rate 6.66% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 4% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 6.98% |
8.2%
1.2 pts worse
|
Numerator 9 · Denominator 129 |
| Staff flu vaccination coverage | 38.13% |
42%
3.9 pts worse
|
Numerator 61 · Denominator 160 |
| Discharge function score | 71.08% |
56.45%
14.6 pts better
|
Numerator 59 · Denominator 83 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 59 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 34.78% |
25.2%
9.6 pts better
|
Numerator 16 · Denominator 46 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.3
1.5 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
91.6%
7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.3%
3.8 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.2% · Q3 6.2% · Q4 6.9% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
50.3%
49.1 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
6.5%
2.5 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 15.8% · Q3 7.4% · Q4 10.2% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
18.5%
0.2 pts worse
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 16.7% · Q3 19.6% · Q4 19.7% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.3% |
22.8%
10.5 pts worse
|
16.7%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 33.3% · Q3 31.2% · Q4 34.0% · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.4% |
17.2%
15.2 pts worse
|
16.3%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 35.7% · Q3 43.8% · Q4 15.5% · 4Q avg 32.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.2% |
15.0%
22.2 pts worse
|
14.9%
22.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 24.0% · Q3 48.1% · Q4 30.2% · 4Q avg 37.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.1%
0.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.7%
1.5 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.6% · Q3 6.5% · Q4 1.5% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
21.3%
2.3 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 22.8% · Q3 24.0% · Q4 15.4% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
5.2%
3.2 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 9.8% · Q3 8.1% · Q4 9.1% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
68.8%
27 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 94.1% · Q3 95.5% · Q4 98.7% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
14.0%
2 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 10.8% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.3%
1.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
63.0%
30.2 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
26.2%
0.3 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 24.2% · Expected 21.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Environmental (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-29
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-13
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-05-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-13
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-05-29
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-30
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-30
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-18
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-11-18
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-10-27
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-11
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-11
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-12
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-05-13
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-05-22
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-12
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-16
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-16
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-05-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-04
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-07-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-02
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-27
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-27
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-27
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-06-27
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-27
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-27
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-20
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-07-15
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-07-15
Health
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.
Corrected 2023-07-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-15
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-07-15
Health
Keep all essential equipment working safely.
Corrected 2023-07-15
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-07-15
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-12
Penalties and ownership
Payment Denial · denial start 2025-05-31 · 13 days
13 day denial
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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