Shelbyville, IL

Shelbyville Manor

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

Compare this facility

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

Facility snapshot

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

Hours and turnover

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

Value-based purchasing

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

How the VBP score is built

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

Medicare quality reporting measures

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

Resident outcomes and process scores

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

Recent inspection cycles

Cycle 1 Health 2025-05-02 · Fire 2025-05-02

15 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-06-07 · Fire 2024-06-07

14 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2023-06-28 · Fire 2023-06-28

9 health deficiencies

Top issue: Environmental (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-02

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-05-29

F · Potential for more than minimal harm 2025-05-02

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2025-05-13

F · Potential for more than minimal harm 2025-05-02

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2025-05-29

F · Potential for more than minimal harm 2025-05-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-05-02

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2025-05-29

F · Potential for more than minimal harm 2025-05-02

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2025-05-30

F · Potential for more than minimal harm 2025-05-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-22

F · Potential for more than minimal harm 2025-05-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-30

E · Potential for more than minimal harm 2025-05-02

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-05-22

F · Potential for more than minimal harm 2024-06-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected

F · Potential for more than minimal harm 2024-06-07

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected

F · Potential for more than minimal harm 2024-06-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected

E · Potential for more than minimal harm 2024-06-07

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected

E · Potential for more than minimal harm 2024-06-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-11-18

E · Potential for more than minimal harm 2025-11-16

F921 · Environmental Deficiencies

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

G · Actual harm 2025-10-23

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-10-27

E · Potential for more than minimal harm 2025-07-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-08-11

D · Potential for more than minimal harm 2025-07-22

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-08-11

G · Actual harm 2025-05-02

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

G · Actual harm 2025-05-02

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-05-12

E · Potential for more than minimal harm 2025-05-02

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2025-05-13

E · Potential for more than minimal harm 2025-05-02

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-05-22

E · Potential for more than minimal harm 2025-05-02

F690 · Quality of Life and Care Deficiencies

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

D · Potential for more than minimal harm 2025-05-02

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-05-12

D · Potential for more than minimal harm 2025-05-02

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-05-22

D · Potential for more than minimal harm 2025-05-02

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-05-16

D · Potential for more than minimal harm 2025-05-02

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-05-16

D · Potential for more than minimal harm 2025-05-02

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2025-05-16

D · Potential for more than minimal harm 2024-11-08

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-11-15

G · Actual harm 2024-09-27

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-06-07

F801 · Nutrition and Dietary Deficiencies

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

F · Potential for more than minimal harm 2024-06-07

F812 · Nutrition and Dietary Deficiencies

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

E · Potential for more than minimal harm 2024-06-07

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-06-26

E · Potential for more than minimal harm 2024-06-07

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-06-27

E · Potential for more than minimal harm 2024-06-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-07

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-07

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-07

F690 · Quality of Life and Care Deficiencies

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

D · Potential for more than minimal harm 2024-06-07

F758 · Pharmacy Service Deficiencies

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

D · Potential for more than minimal harm 2024-06-07

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-07

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-03-13

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

F · Potential for more than minimal harm 2023-06-28

F727 · Nursing and Physician Services Deficiencies

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

F · Potential for more than minimal harm 2023-06-28

F801 · Nutrition and Dietary Deficiencies

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

D · Potential for more than minimal harm 2023-06-28

F578 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2023-06-28

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-28

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-28

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-28

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2023-07-15

C · Minimal harm 2023-06-28

F803 · Nutrition and Dietary Deficiencies

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

D · Potential for more than minimal harm 2023-05-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

What sits behind the stars

$0 2025-05-02

Payment Denial

Payment Denial · denial start 2025-05-31 · 13 days

13 day denial

Ownership

Dailey, Karen

W-2 Managing Employee · Individual

0% 1 facilities 2006-02-02
Finke, Audrey

Corporate Director · Individual

0% 10 facilities 2018-08-30
Gilmore, Jerry

Corporate Director · Individual

0% 10 facilities 2006-02-02
Haney, David

Corporate Director · Individual

0% 11 facilities 2006-02-02
Udi #3, LLC

Operational/Managerial Control · Organization

0% 1 facilities 2006-02-02
Wagner, Robert

Corporate Director · Individual

0% 10 facilities 2006-02-02
Wagner, Robert

Corporate Officer · Individual

0% 10 facilities 2018-08-30
Wilson, Ronald

Corporate Officer · Individual

0% 17 facilities 2018-08-30

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