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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 254th out of 287 homes in Indiana. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 27m per day | ▼ 33% State avg: 40m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 56m per day | ▲ 22% State avg: 46m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 23m per day | ▲ 5% State avg: 2h 16m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 2m per day | ▼ 6% State avg: 3h 14m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 3m per day | ▼ 25% State avg: 4m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 15m per day | ▼ 44% State avg: 27m per day · National avg: 28m per day |
Lower than the Indiana average: 68.1%Willows of Shelbyville is legally operated by Major Hospital, and administrated by Mandi Paul.
Key information about the people who lead and staff this community.
In Indiana, the Department of Health, Division of Long Term Care is the primary regulatory body that performs onsite inspections and quality of care reviews for all licensed facilities.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Indiana state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 58 | 36 | This facility has 61% more total deficiencies than a typical Indiana nursing home (58 vs. IN avg 36).↑ 61% worse |
|
Deficiencies per year
Average deficiencies per year since 2022.
| 14.5 | 9 | This facility has 61% more deficiencies per year than a typical Indiana nursing home (14.5 vs. IN avg 9).↑ 61% worse |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 2.2 | 1.9 | This facility has 16% more deficiencies per inspection than a typical Indiana nursing home (2.2 vs. IN avg 1.9).↑ 16% worse |
Inspections
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total visits
Combined count of all on-site visits — routine inspections, complaint visits, follow-ups, and other focused visits.
| 26 | 19 | This facility has 37% more total visits than a typical Indiana nursing home (26 vs. IN avg 19).↑ 37% worse |
|
Inspections with deficiencies
Inspections that resulted in at least one regulatory deficiency.
| 10 | 7 | This facility has 43% more inspections with deficiencies than a typical Indiana nursing home (10 vs. IN avg 7).↑ 43% worse |
|
Inspection deficiency rate
Percentage of inspections that resulted in at least one deficiency.
| 38% | 37% | This facility has 1 percentage point higher inspection deficiency rate than a typical Indiana nursing home (38% vs. IN avg 37%).↑ 1% worse |
|
Inspections
Routine, scheduled inspections conducted by state regulators.
| 19 | 13 | This facility has 46% more inspections than a typical Indiana nursing home (19 vs. IN avg 13).↑ 46% worse |
Complaints & Investigations
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 6 | 5 | This facility has 20% more total complaints than a typical Indiana nursing home (6 vs. IN avg 5).↑ 20% worse |
|
Complaints per year
Average complaints per year since 2022.
| 1.5 | 1.3 | This facility has 15% more complaints per year than a typical Indiana nursing home (1.5 vs. IN avg 1.3).↑ 15% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspection on June 18, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern, with several citations related to kitchen sanitation, life safety code violations, and care planning deficiencies. Main issues included maintaining kitchen cleanliness and sanitization, life safety code compliance such as egress obstructions and door functionality, and behavioral health care documentation and interventions. Complaint investigations were mostly unsubstantiated, though some prior complaints were substantiated with deficiencies cited, particularly involving resident care and medication administration. The facility’s recent inspections indicate some improvement in addressing prior concerns, especially in complaint investigations and life safety compliance.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsIndiana average 6
Last Health inspection on Mar 2025
Indiana average 25
Indiana average 4.12
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
23 of 34 citations resulted from standard inspections; 9 of 34 resulted from complaint investigations; and 2 of 34 came from combined inspections (standard and complaint).
100% better than Indiana averageIndiana average: 0.2
67% worse than Indiana averageIndiana average: 0.6
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
3947268% better than Indiana average
0% compared with Indiana average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
10 hoursThis role is partially covered by contractors.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.3 hoursThis role is partially covered by contractors.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.2 hoursThis role is partially covered by contractors.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
2,589 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 61 | 70 | 131 | 14,780 | 92 | 100% | 7.2 |
| Licensed Practical Nurse | 20 | 21 | 41 | 5,877 | 92 | 100% | 9.3 |
| Medication Aide/Technician | 11 | 5 | 16 | 4,718 | 92 | 100% | 8.1 |
| Other Dietary Services Staff | 6 | 0 | 6 | 1,530 | 88 | 96% | 6.1 |
| Registered Nurse | 4 | 1 | 5 | 1,408 | 86 | 93% | 10 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 1,031 | 74 | 80% | 8.8 |
| RN Director of Nursing | 3 | 0 | 3 | 1,017 | 84 | 91% | 7.5 |
| Nurse Practitioner | 1 | 0 | 1 | 658 | 87 | 95% | 7.6 |
| Administrator | 1 | 0 | 1 | 528 | 66 | 72% | 8 |
| Mental Health Service Worker | 1 | 1 | 2 | 520 | 64 | 70% | 7.9 |
| Dietitian | 1 | 0 | 1 | 503 | 63 | 68% | 8 |
| Respiratory Therapy Technician | 3 | 0 | 3 | 328 | 62 | 67% | 5.2 |
| Physical Therapy Aide | 4 | 0 | 4 | 306 | 65 | 71% | 4.6 |
| Physical Therapy Assistant | 1 | 0 | 1 | 289 | 60 | 65% | 4.8 |
| Respiratory Therapist | 1 | 0 | 1 | 263 | 65 | 71% | 4 |
| Medical Director | 0 | 1 | 1 | 160 | 40 | 43% | 4 |
| Speech Language Pathologist | 2 | 0 | 2 | 120 | 36 | 39% | 3.3 |
| Occupational Therapy Aide | 0 | 1 | 1 | 115 | 30 | 33% | 3.8 |
| Qualified Social Worker | 2 | 0 | 2 | 67 | 22 | 24% | 3.1 |
| Occupational Therapy Assistant | 1 | 0 | 1 | 58 | 12 | 13% | 4.8 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
15.1
89% worse than Indiana averageIndiana average: 8.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
30.3
78% worse than Indiana averageIndiana average: 17.1
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
20.7%
72% worse than Indiana averageIndiana average: 12.0%
Percent of long-stay residents whose ability to move independently worsened
37.4%
161% worse than Indiana averageIndiana average: 14.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
32.9%
34% worse than Indiana averageIndiana average: 24.6%
Percent of long-stay residents experiencing one or more falls with major injury
10.7%
178% worse than Indiana averageIndiana average: 3.9%
Percent of long-stay high risk residents with pressure ulcers
0.9%
81% better than Indiana averageIndiana average: 4.4%
Percent of long-stay residents with a urinary tract infection
0.9%
28% better than Indiana averageIndiana average: 1.2%
Percent of long-stay residents who lose too much weight
6.0%
6% worse than Indiana averageIndiana average: 5.7%
Percent of long-stay residents who have depressive symptoms
69.0%
186% worse than Indiana averageIndiana average: 24.1%
Percent of long-stay residents who received an antipsychotic medication
24.9%
100% worse than Indiana averageIndiana average: 12.4%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
100.0%
7% better than Indiana averageIndiana average: 93.7%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
100.0%
5% better than Indiana averageIndiana average: 95.4%
Number of hospitalizations per 1,000 long-stay resident days.
2.18
36% worse than Indiana averageIndiana average: 1.60
Number of outpatient emergency department visits per 1,000 long-stay resident days.
0.86
42% better than Indiana averageIndiana average: 1.48
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
100.0%
22% better than Indiana averageIndiana average: 81.7%
Percent of short-stay residents who newly received an antipsychotic medication
0.8%
45% better than Indiana averageIndiana average: 1.4%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
98.6%
25% better than Indiana averageIndiana average: 79.0%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
11.4%
49% better than Indiana averageIndiana average: 22.4%
Percentage of short-stay residents who had an outpatient emergency department visit.
6.5%
38% better than Indiana averageIndiana average: 10.5%
Percentage of SNF residents who experience falls with major injury during their stay.
3.3%
332% worse than Indiana averageIndiana average: 0.8%
Rate of successful return to home or community from a skilled nursing facility.
55.5%
10% better than Indiana averageIndiana average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
40% of new residents, usually for short-term rehab.
25% of new residents, often for short stays.
34% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
57Residents meet regularly to discuss policies, care quality, and activities
State-approved Nurse Aide Training and Competency Evaluation Program on-site
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for Willows of Shelbyville based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #219 / 290Payroll — State benchmarkedThis home is ranked 219th out of 290 homes in Indiana. Shows total annual staff payroll benchmarked to the Indiana average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Most residents typically stay for a few weeks or months before returning home or moving on.
0.0 miles from city center
Estimated distance in miles from Shelbyville's city center to Willows of Shelbyville's address, calculated via Google Maps.
Add your location
Willows of Shelbyville is located in SHELBYVILLE, Indiana.
Here are the financial assistance programs available to residents in Indiana.
The information below is reported by the Indiana Department of Health, Division of Long Term Care.
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NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
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HC Home Care Professional care delivered in the person's own home — from companionship and errands to skilled nursing and therapy. Allows seniors to age in place. Medicare covers skilled home health when medically necessary.
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| Willows of Shelbyville |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
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Amber Pearson is the Director of Nursing at Willows of Shelbyville.
The legal owner and operator of Willows of Shelbyville is Major Hospital.
Willows of Shelbyville has a walk score of 77. Very walkable. Most errands can be accomplished on foot, and many essentials are within a short walk.
According to IN state health department records, Willows of Shelbyville's license number is 25-000009-1.
According to IN state health department records, Willows of Shelbyville's license expires on December 31, 2025.
Willows of Shelbyville's occupancy is 58%.
Mandi Paul is the administrator of Willows of Shelbyville.
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