Shelbyville Manor: Unlawful Restraint Caused Resident Fracture - IL
When inspectors arrived on October 21, they asked a nursing assistant about the pillows. The aide said they were placed under the sheet specifically to keep the resident from getting up and walking by herself. The resident's chart contained no assessment for them and no care plan entry.
A licensed practical nurse confirmed the same thing: staff had been told by the facility to keep the body pillows in place while the resident was in bed. There was no documentation authorizing it.
The Director of Nursing acknowledged to inspectors that a restraint assessment should have been completed before the pillows were used, and again after each fall. She reviewed the electronic medical record on the spot and confirmed neither assessment existed. She also confirmed the fracture was connected to the October 10 fall, and that the body pillows were already in place on the bed before that fall occurred.
The resident's hospice nurse practitioner told inspectors the setup made things worse. Placing full-length body pillows on top of a concave mattress created an extra obstacle for the resident to climb over, increasing her risk of injury. The resident had cognitive impairment, was ambulatory, and was taking pain medication, all of which the nurse practitioner said elevated her fall and injury risk further.
The facility's own restraint policy, last revised in November 2017, lists using a concave mattress to prevent a resident from getting out of bed as an example of a physical restraint. That same policy requires an assessment before any restraint is used and a reassessment every 90 days.
None of that happened. Staff were simply told to keep the pillows there. The resident fell, fractured a bone, and the paperwork was never started.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shelbyville Manor from 2025-10-23 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
SHELBYVILLE MANOR in SHELBYVILLE, IL was cited for violations during a health inspection on October 23, 2025.
When inspectors arrived on October 21, they asked a nursing assistant about the pillows.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.