Inspection Report Summary
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.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
245% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Jun 18, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457386.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457386 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 9
Medicaid census: 48
Other payor census: 13
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 1, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00454870 completed on March 6, 2025.
Findings
Willows of Shelbyville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Complaint IN00454870 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 1
Mar 6, 2025
Visit Reason
This visit was for the investigation of complaints IN00453912 and IN00454870. Complaint IN00454870 resulted in federal/state deficiencies cited, while complaint IN00453912 had no deficiencies related to the allegations.
Findings
The facility failed to maintain kitchen equipment in a clean manner and ensure sanitizing buckets were at proper sanitization levels, potentially affecting all 71 residents. Observations included expired test strips for sanitization buckets, a brown fuzzy substance on storage racks in the walk-in refrigerator, and incomplete cleaning practices.
Complaint Details
Complaint IN00454870 was substantiated with federal/state deficiencies cited at F812. Complaint IN00453912 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain kitchen equipment in a clean manner and ensure sanitizing buckets were at proper sanitization levels. | SS=F |
Report Facts
Census: 71
Total Capacity: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mandi Paul | Dietary Manager | Interviewed regarding kitchen sanitation and cleaning deficiencies |
| Executive Director | Interviewed regarding expired test strips and cleaning issues |
Inspection Report
Life Safety
Census: 65
Capacity: 141
Deficiencies: 0
Nov 26, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/21/24 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Willows of Shelbyville was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 7, 2024
Visit Reason
Paper compliance review related to the Recertification and State Licensure survey and the Investigation of Complaint IN00444117 completed on October 1, 2024.
Findings
Willows of Shelbyville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey and the complaint investigation. The complaint IN00444117 was corrected.
Complaint Details
Complaint IN00444117 was investigated and found to be corrected.
Inspection Report
Life Safety
Census: 60
Capacity: 141
Deficiencies: 12
Oct 21, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 10/21/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified related to corridor egress obstructions, exit door accessibility, discharge from exits, exit signage, hazardous area door self-closing devices, kitchen hood extinguishing system, sprinkler system installation, corridor door latching, HVAC return air system use in egress corridors, and improper use of multi-plug adapters and extension cords.
Severity Breakdown
SS=E: 11
SS=F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 4 corridor means of egress were continuously maintained free of obstructions; a PPE cart without wheels blocked corridor egress. | SS=E |
| Failed to ensure 1 of over 8 exterior exit doors were readily accessible, not blocked and able to open on first try; double exit doors blocked by sandbags. | SS=F |
| Failed to ensure 1 of over 8 exit discharges was free of obstructions; employee vehicle parked blocking kitchen exit discharge. | SS=E |
| Failed to ensure 1 of over 8 doors to the outside were not mistaken as a facility exit; exit sign chevron pointed to inaccessible exit door. | SS=E |
| Failed to ensure 5 of over 10 hazardous area doors had properly working self-closing devices. | SS=E |
| Failed to provide an approved method for returning cooking appliances to approved location after maintenance; kitchen range hood extinguishing system non-compliant. | SS=E |
| Failed to install kitchen range hood system with required drip trays beneath filters. | SS=E |
| Failed to maintain sprinkler system ceiling construction; sprinkler head protruding with gap around sprinkler and ceiling. | SS=E |
| Failed to ensure 3 of over 50 corridor doors had no impediment to closing and latching and would resist passage of smoke. | SS=E |
| Failed to ensure 5 of 14 egress corridors were not used as a portion of HVAC return air system/plenum. | SS=E |
| Failed to ensure 1 of over 60 resident rooms did not use multi-plug adaptors as a substitute for fixed wiring. | SS=E |
| Failed to ensure 1 of 1 flexible cords in kitchen were not used as a substitute for fixed wiring. | SS=E |
Report Facts
Certified beds: 141
Census: 60
Residents potentially affected: 15
Residents potentially affected: 13
Staff potentially affected: 6
Staff potentially affected: 8
Staff potentially affected: 2
Residents potentially affected: 2
Staff potentially affected: 6
Estimated cost: 100000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mandi Paul | Maintenance Director | Named in multiple findings and interviews regarding deficiencies and corrective actions. |
Inspection Report
Recertification
Census: 57
Capacity: 57
Deficiencies: 7
Oct 1, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of Complaints IN00437948 and IN00444117.
Findings
The facility was found deficient in multiple areas including failure to accurately document residents' code status, inaccurate MDS assessments, failure to conduct timely care plan meetings, incomplete neurological checks after a fall, inadequate dementia care with wandering residents, improper food storage and kitchen sanitation, and maintenance issues in the kitchen.
Complaint Details
Complaint IN00437948 - No deficiencies related to the allegations are cited. Complaint IN00444117 - Federal/State deficiencies related to the allegations are cited at F684 (failure to ensure neurological checks after a fall).
Severity Breakdown
SS=D: 4
SS=E: 1
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to accurately document a resident's code status in the clinical record for 1 of 1 resident reviewed for advanced directives. | SS=D |
| Failed to encode minimum data set (MDS) assessments accurately for 2 of 2 residents reviewed for MDS accuracy. | SS=D |
| Failed to conduct care plan meetings for 1 of 4 residents reviewed for care plans. | SS=D |
| Failed to ensure neurological checks, including vital signs, were fully conducted for a resident who experienced an unwitnessed fall. | SS=D |
| Failed to redirect residents with wandering behaviors from other residents' rooms resulting in lack of privacy for 5 of 8 residents reviewed for dementia care. | SS=E |
| Failed to store food and silverware properly and wear hair restraints in the kitchen, potentially affecting all residents. | SS=F |
| Failed to maintain the kitchen in a clean manner and in good repair, including missing tiles, dirt and debris, and unclean surfaces. | SS=F |
Report Facts
Census: 57
Total Capacity: 57
Residents reviewed for care plans: 4
Residents reviewed for MDS accuracy: 2
Residents reviewed for dementia care: 8
Residents affected by wandering behaviors: 5
Residents affected by food storage and kitchen sanitation: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook 5 | Cook | Named in relation to failure to wear hair restraint and improper food handling |
| Director of Nursing | Director of Nursing | Interviewed regarding code status documentation and provided policies |
| Social Service Director | Social Service Director | Interviewed regarding care plan meetings and code status binder |
| Licensed Practical Nurse 4 | LPN | Interviewed regarding wandering residents and lack of scheduled activities |
| Licensed Practical Nurse 5 | LPN | Interviewed regarding wandering residents and redirection efforts |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment inaccuracies |
| Dietary Supervisor | Dietary Supervisor | Interviewed during kitchen tour regarding food storage and sanitation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Jun 20, 2024
Visit Reason
This visit was for the investigation of Complaint IN00436423.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Investigation of Complaint IN00436423. No deficiencies related to the allegations are cited.
Report Facts
Census: 57
Total Capacity: 57
Medicare Census: 7
Medicaid Census: 35
Other Payor Census: 15
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00433897, IN00434609, IN00435564, and IN00435642) and was in conjunction with a Post Survey Revisit to previous complaint investigations completed on 2024-05-02.
Findings
No deficiencies related to the allegations in complaints IN00433897, IN00434609, IN00435564, and IN00435642 were cited. Previous complaints investigated during the Post Survey Revisit were found to be corrected. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00433897, IN00434609, IN00435564, and IN00435642 had no deficiencies related to the allegations cited. Complaints IN00429302, IN00432416, IN00432418, IN00432991, and IN00433278 were corrected as of the Post Survey Revisit.
Report Facts
Census SNF/NF: 59
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 40
Census Payor Type Other: 15
Inspection Report
Follow-Up
Census: 59
Deficiencies: 0
Jun 5, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00429302, IN00432416, IN00432418, IN00432991, and IN00433278 completed on 2024-05-02, conducted in conjunction with investigations of additional complaints.
Findings
The facility was found to be in compliance with relevant regulations regarding the complaints investigated. Several complaints were corrected, and no deficiencies related to other complaints were cited.
Complaint Details
The visit addressed multiple complaints: IN00429302, IN00432416, IN00432418, IN00432991, and IN00433278 were corrected. Complaints IN00433897, IN00434609, IN00435564, and IN00435642 had no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 59
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 40
Census Payor Type Other: 15
Total Census: 59
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 3
May 2, 2024
Visit Reason
This visit was for the investigation of multiple complaints related to the facility, including allegations of behavioral health care deficiencies, resident-to-resident abuse, and medication administration issues.
Findings
The facility failed to ensure proper behavioral health care and documentation for Resident E, including failure to document behaviors and interventions, and failure to ensure safety of other residents, resulting in physical aggression and harm. The facility also failed to provide appropriate care plans and interventions for sexually inappropriate behaviors of Resident H, who touched other residents inappropriately. Additionally, the facility failed to administer narcotic medications per physician orders for Residents E and D.
Complaint Details
The investigation was triggered by multiple complaints (IN00429302, IN00432416, IN00432418, IN00432991, IN00433278) alleging deficiencies in behavioral health services, resident-to-resident abuse, and medication administration. Some complaints were substantiated with federal/state deficiencies cited, while others were not.
Severity Breakdown
SS=G: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement and evaluate behavioral health care plan for Resident E, including documentation of behaviors and interventions, and ensuring safety of other residents. | SS=G |
| Failure to provide appropriate treatment and services for dementia-related behaviors, including sexually inappropriate behaviors by Resident H. | SS=D |
| Failure to ensure accurate administration and documentation of narcotic medications for Residents E and D. | SS=D |
Report Facts
Census SNF/NF beds: 64
Residents on 15-minute checks: 1
Missed medication administrations: 12
Missed medication administrations: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mandi Paul | Administrator in Training (AIT) | Interviewed regarding complaint investigations and provided facility policies |
| Licensed Practical Nurse 2 | Interviewed about Resident E's behaviors | |
| Licensed Practical Nurse 3 | Interviewed about Resident H's behaviors | |
| Social Services Director (SSD) | Interviewed about behavioral health provider changes and resident monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 1, 2024
Visit Reason
This document is a paper compliance review related to a Complaint Investigation completed on February 22, 2024.
Findings
Willows of Shelbyville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Paper compliance review to the Complaint Investigation completed on February 22, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 5
Feb 22, 2024
Visit Reason
This visit was for the investigation of complaints IN00422534, IN00427915, IN00427968, and IN00428299.
Findings
The facility was found to have deficiencies related to complaint IN00427915 involving activities of daily living, respiratory care, pain management, medication labeling/storage, and infection prevention and control. Other complaints had no deficiencies related to the allegations.
Complaint Details
Complaint IN00427915 was substantiated with federal/state deficiencies cited at F676, F695, and F697. Complaints IN00422534, IN00427968, and IN00428299 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a resident's preference for frequency of bathing was honored for 1 of 4 residents reviewed. | SS=D |
| Failed to ensure oxygen therapy supplies were maintained in a clean and hygienic manner for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure 1 of 4 residents reviewed for pain medication received pain medications as ordered by their physician. | SS=D |
| Failed to ensure an insulin pen was properly labeled for use for 1 of 4 residents observed during medication pass. | SS=D |
| Failed to ensure facility staff appropriately sanitized a glucometer utilized for multiple residents. | SS=D |
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 5
Medicaid Census: 45
Other Payor Census: 18
Inspection Report
Re-Inspection
Census: 68
Capacity: 141
Deficiencies: 0
Nov 2, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/14/23.
Findings
At this PSR Emergency Preparedness survey, Willows of Shelbyville was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, the facility was found in compliance with Life Safety Code requirements including fire safety and sprinkler systems.
Report Facts
Certified beds: 141
Census: 68
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Oct 26, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419742 and IN00420345 at the facility.
Findings
No deficiencies related to the allegations in complaints IN00419742 and IN00420345 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00419742 and IN00420345 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census Bed Type: 67
Medicare Census: 6
Medicaid Census: 45
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Oct 11, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00418692.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00418692 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 64
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 15
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 26, 2023
Visit Reason
Paper compliance review to the Recertification, State Licensure, and Complaint IN00406333 completed on July 26, 2023.
Findings
Willows of Shelbyville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification, State Licensure, and Complaint.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Sep 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417416 at the facility.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00417416. No deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 65
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 16
Inspection Report
Routine
Census: 63
Capacity: 141
Deficiencies: 16
Aug 14, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with emergency preparedness requirements, including outdated transfer agreements, incomplete communication plans, lack of annual emergency preparedness training, and multiple life safety code deficiencies such as inaccessible locked rooms, malfunctioning exit door codes, inadequate emergency lighting testing, self-closing door failures, missing sprinkler escutcheons, unprotected smoke barriers, exposed electrical wiring, unsecured electrical panels, missing outlet faceplates, and HVAC return air issues using egress corridors.
Severity Breakdown
C: 4
E: 8
F: 4
Deficiencies (16)
| Description | Severity |
|---|---|
| Emergency preparedness policies failed to include updated transfer agreements with other LTC facilities. | C |
| Emergency preparedness communication plan lacked current names and contact information for staff, physicians, and other entities. | C |
| Emergency preparedness communication plan did not include contact information for the State Long Term Care Ombudsman. | C |
| Facility failed to conduct and document annual emergency preparedness training and staff knowledge demonstration. | C |
| Keys to 10 rooms used for storage were not accessible to staff, impeding emergency egress. | E |
| Two exit doors were magnetically locked with incorrect posted codes, restricting egress. | E |
| Facility failed to document monthly and annual testing of battery backup emergency lights; one light was disconnected. | F |
| Six hazardous area doors failed to self-close and latch properly, risking smoke passage. | E |
| Two hazardous rooms had unsealed penetrations in corridor doors compromising smoke resistance. | E |
| Fire department connection lacked identification signage and missing caps; sprinkler escutcheon missing in storage room. | F |
| Spare sprinkler heads were not properly stored in cabinets; sprinkler heads in beauty salon were dusty. | F |
| Office area open to corridor lacked required smoke detection. | E |
| Nine corridor doors failed to latch properly and had impediments to closing, risking smoke passage. | E |
| Smoke barrier walls had large holes compromising smoke resistance. | E |
| Electrical junction box in renovation area lacked cover and had exposed wiring; electrical panel unsecured; missing outlet faceplate. | E |
| HVAC system used egress corridors as return air plenum without proper smoke control, risking smoke spread. | E |
Report Facts
Certified beds: 141
Census: 63
Deficiency count: 16
Rooms inaccessible: 10
Exit doors with incorrect codes: 2
Hazardous area doors failing self-close: 6
Corridor doors failing to latch: 9
Sprinkler heads loose in cabinet: 9
Sprinkler heads dusty: 2
Electrical panels unsecured: 1
Missing outlet faceplates: 1
HVAC corridors used as return air plenum: 5
Inspection Report
Annual Inspection
Census: 63
Capacity: 63
Deficiencies: 10
Jul 26, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00406333.
Findings
The facility was found deficient in multiple areas including resident dignity, Medicaid/Medicare coverage notices, safe environment maintenance, grievance handling, comprehensive care planning, ADL care, accident prevention, catheter care, hydration, and infection control.
Complaint Details
Complaint IN00406333 was investigated during this visit. Federal deficiencies related to the allegations were cited at F550 regarding Resident Rights/Exercise of Rights.
Severity Breakdown
SS=D: 9
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure a dignified environment for 2 residents. | SS=D |
| Failed to provide beneficiary notices for 1 resident. | SS=D |
| Failed to ensure overhead light fixtures were free of dead insects. | SS=E |
| Failed to file a grievance for a resident voicing missing personal property. | SS=D |
| Failed to ensure a care plan was initiated for the utilization of a splint for 1 resident. | SS=D |
| Failed to provide supervision and/or assistance for 3 residents observed for eating. | SS=D |
| Failed to ensure utilization of a gait belt during a transfer for 1 resident. | SS=D |
| Failed to document urinary catheter outputs as careplanned for 1 resident. | SS=D |
| Failed to ensure water pitchers were available for resident utilization for 2 residents. | SS=D |
| Failed to ensure hand hygiene was performed between contact with multiple residents during dining service. | SS=D |
Report Facts
Census: 63
Total Capacity: 63
Survey Dates: July 20, 21, 24, 25, 26, 2023
Deficiency Counts: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 8 | Licensed Practical Nurse | Named in findings related to dignity, feeding assistance, and gait belt use |
| LPN 9 | Licensed Practical Nurse | Named in hydration and splint care findings |
| CNA 3 | Certified Nursing Assistant | Mentioned in grievance and feeding observations |
| CNA 4 | Certified Nursing Assistant | Observed assisting residents with eating |
| CNA 5 | Certified Nursing Assistant | Interviewed about catheter output documentation |
| CNA 10 | Certified Nursing Assistant | Observed assisting resident transfer without gait belt |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding policies and findings |
| Housekeeping Staff 6 | Interviewed regarding resident behaviors and meal supervision | |
| Administrator | Administrator | Interviewed regarding light fixture cleaning |
| Bookkeeper | Interviewed regarding Medicaid notification process |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 0
Feb 9, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00399240 and IN00401014.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00399240 - Substantiated with no deficiencies cited. Complaint IN00401014 - Substantiated with no deficiencies cited.
Report Facts
Medicare residents: 6
Medicaid residents: 41
Other residents: 14
Inspection Report
Life Safety
Census: 60
Capacity: 141
Deficiencies: 2
Dec 5, 2022
Visit Reason
The survey was conducted as a Pre-Occupancy Life Safety Code Recertification and State Licensure Survey, including a request for bed additions and renovations of rooms from 1-bed to 2-bed configurations.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with egress door locking arrangements and missing sprinkler escutcheons. These deficiencies could affect staff, residents, and visitors, but no one was reported as affected at the time of the survey.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through the service hall exit was readily accessible; exit door near RR 80 was magnetically locked with a code not posted at the exit. | SS=E |
| Failed to maintain ceiling construction in accordance with NFPA 13; sprinkler heads missing escutcheons in multiple resident rooms and corridor. | SS=E |
Report Facts
Facility capacity: 141
Census: 60
Number of rooms renovated: 10
Number of rooms renovated: 6
Number of rooms renovated: 1
Number of rooms renovated: 15
Number of rooms renovated: 7
Number of sprinkler heads missing escutcheons: 5
Number of staff and visitors potentially affected: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlson David DePrez | Administrator | Named in relation to acknowledgment of findings during exit conference |
| Maintenance Director | Participated in observations and interviews regarding deficiencies | |
| Executive Director | Participated in observations and interviews regarding deficiencies |
Inspection Report
Life Safety
Deficiencies: 0
Dec 5, 2022
Visit Reason
Paper compliance to the Life Safety Code and Preoccupancy Survey was conducted on 12/05/22 and completed on 12/27/22.
Findings
Heritage House of Shelbyville was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 15, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00388818 completed on September 23, 2022.
Findings
Heritage House of Shelbyville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00388818; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 2
Sep 23, 2022
Visit Reason
This visit was for the investigation of three substantiated complaints (IN00388818, IN00390109, and IN00390677) concerning resident care and notification of changes in condition.
Findings
The facility was found deficient in ensuring privacy and dignity during diabetic care for one resident, and in promptly notifying the attending physician of a resident's change in condition, which contributed to hospitalization. Other complaints were substantiated but had no related deficiencies cited.
Complaint Details
Complaint IN00388818 was substantiated with a federal/state deficiency cited at F580 related to notification of changes. Complaints IN00390109 and IN00390677 were substantiated but had no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure privacy and dignity during diabetic care for 1 of 1 residents receiving diabetic care (Resident F). | SS=D |
| Failed to notify the attending physician and/or nurse practitioner promptly of a resident's change in condition, contributing to hospitalization (Resident D). | SS=D |
Report Facts
Census: 60
Total Capacity: 60
Medicare Census: 3
Medicaid Census: 46
Other Payor Census: 11
Units of Insulin Administered: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Observed administering diabetic care without privacy and interviewed regarding the practice and Resident D care | |
| Director of Nursing | Interviewed regarding facility policies and education plans for privacy and notification of changes | |
| Nurse Practitioner (NP 4) | Interviewed regarding Resident D's condition and expectations for notification |
Inspection Report
Life Safety
Census: 66
Capacity: 141
Deficiencies: 0
Aug 2, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/08/22 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Heritage House of Shelbyville was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detection in corridors and resident sleeping rooms.
Report Facts
Facility capacity: 141
Census: 66
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