Cycle 1
Health 2025-12-23 · Fire 2025-12-23
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
12 fire-safety deficiencies
Top issue: Services (3 deficiencies)
Shelbyville, IN
Willows Of Shelbyville
1-star overall rating with 2-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
2309 S Miller St, Shelbyville, IN
(317) 398-9781
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
76
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.46
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
2.71
CMS adjusted total nurse staffing hours
Case-mix index
1.90
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,778
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.68
Performance 18.34% · Measure score 6.68 · Achievement 6.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.75
Performance 7.01% · Measure score 2.75 · Achievement 2.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.63
Baseline 41.03% · Performance 52.94% · Measure score 2.63 · Achievement 2.63 · Improvement 0
Adjusted total nurse staffing
1.98
Baseline 2 hours · Performance 2.94 hours · Measure score 1.98 · Achievement 0 · Improvement 1.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 6.98% · Lower 95% interval 5.96% |
| Discharge to community | 55.46% |
50.57%
4.9 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 46.67% · Lower 95% interval 40.33% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 1 · Denominator 30 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 171 |
| Staff flu vaccination coverage | 74.32% |
42%
32.3 pts better
|
Numerator 136 · Denominator 183 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 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 | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.4% |
3.8%
8.6 pts worse
|
3.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.3% · Q3 17.2% · Q4 14.5% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 67.7% |
24.6%
43.1 pts worse
|
11.4%
56.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.8% · Q2 66.1% · Q3 72.6% · Q4 62.3% · 4Q avg 67.7% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.6%
0.1 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 3.8% · Q3 3.6% · Q4 5.0% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.1% |
23.5%
7.6 pts worse
|
19.6%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 29.1% · Q3 33.9% · Q4 34.4% · 4Q avg 31.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.1% |
14.8%
15.3 pts worse
|
16.7%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 33.3% · Q3 30.4% · Q4 30.9% · 4Q avg 30.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 33.6% |
13.3%
20.3 pts worse
|
16.3%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 41.9% · Q3 29.9% · Q4 29.5% · 4Q avg 33.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
11.7%
3 pts worse
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 11.5% · Q3 12.7% · Q4 13.8% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.4%
0.4 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.4% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.9% |
24.2%
8.7 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.8% · Q2 25.6% · Q3 25.5% · Q4 40.6% · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.1%
2.8 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 2.2% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
81.6%
18 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.4% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
10.5%
4 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.0% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
79.0%
19.6 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.4% |
22.4%
11 pts better
|
23.9%
12.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.6% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-01 · Fire 2024-10-01
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-07-26 · Fire 2023-07-26
15 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Not marked corrected
F · Potential for more than minimal harm
2025-12-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Not marked corrected
F · Potential for more than minimal harm
2025-12-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Not marked corrected
E · Potential for more than minimal harm
2025-12-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Not marked corrected
C · Minimal harm
2025-12-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Not marked corrected
F · Potential for more than minimal harm
2024-10-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-07-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-07-26
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-07-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-07-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-07-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-07-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-31
C · Minimal harm
2023-07-26
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-10-31
C · Minimal harm
2023-07-26
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-10-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-23
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-21
F · Potential for more than minimal harm
2025-03-06
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 2025-03-20
F · Potential for more than minimal harm
2024-10-01
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 2024-10-25
F · Potential for more than minimal harm
2024-10-01
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 2024-10-25
E · Potential for more than minimal harm
2024-10-01
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-01
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 2024-10-25
D · Potential for more than minimal harm
2024-10-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-25
G · Actual harm
2024-05-02
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 2024-05-20
D · Potential for more than minimal harm
2024-05-02
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-05-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-02-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
E · Potential for more than minimal harm
2023-07-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-26
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 2023-08-25
D · Potential for more than minimal harm
2023-07-26
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-26
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-26
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 2023-08-25
D · Potential for more than minimal harm
2023-07-26
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 2023-08-25
D · Potential for more than minimal harm
2023-07-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-25
Penalties and ownership
What sits behind the stars
Ownership
Major Hospital
5% Or Greater Direct Ownership Interest · Organization
Claxton, Ryan
Operational/Managerial Control · Individual
Claxton, Ryan
Corporate Officer · Individual
Frankel, Israel
Operational/Managerial Control · Individual
Horner, John
Corporate Officer · Individual
Paul, Mandi
Operational/Managerial Control · Individual
Radadiya, Pragneshkumar
Operational/Managerial Control · Individual
Shelbyville In Opco LLC
Operational/Managerial Control · Organization
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