Shelbyville Manor: Mold and Rust on Water Heaters - IL
That sequence of events came to light during a November 16 complaint inspection at Shelbyville Manor, a nursing home in Shelbyville, Illinois.
The facility's care plan coordinator, identified in inspection records as V7, told inspectors that the power of attorney for a resident known as R1 had called her to report the condition of the water heater in R1's room. The family member's description was direct: mold, rust, and "a bunch of stuff" covering the unit. V7 said she passed the concern to the administrator at the next morning's meeting.
Then she stopped there.
"I don't know whatever was done with that, but I reported it to her," V7 told inspectors. "That was her responsibility then, not mine."
V7 said no progress note was made documenting the family member's call or the concern they raised. She also said she couldn't remember what date the call came in.
The administrator, identified as V1, told inspectors she had been "just made aware" that three of the facility's water heaters had mold, mildew, and rust on them. That framing, offered on the afternoon of the inspection itself, came despite the fact that her own care plan coordinator said she had reported the problem to the administrator at a morning meeting.
V1 acknowledged that the facility has several hot water heaters located in closets inside resident rooms, spread across three different hallways. She said the units "probably" don't get hot enough to pose a fire hazard, but she also said they should not have mold, mildew, and rust on them inside the areas where residents live. She said the maintenance director was working to get the affected units replaced.
The inspection cited the deficiency under F0921, which covers the physical environment, with a finding of minimal harm or potential for actual harm affecting some residents.
What the record shows, though, is a facility where a family member noticed something wrong in a resident's room, made a call, got a sympathetic ear, and then watched the concern dissolve into a morning meeting with no documentation, no follow-up anyone could account for, and no timeline anyone could reconstruct. By the time federal inspectors arrived, the administrator was describing herself as newly informed of a problem her own staff said they had already told her about.
The care plan coordinator's accounting of events was matter-of-fact about where her obligation ended. She reported it up. Whatever happened next was someone else's job. The administrator, for her part, did not dispute that the water heaters had a problem. She confirmed three of them had mold, mildew, and rust. She confirmed they were inside rooms where residents live. She confirmed they needed to be replaced.
She did not say when she first learned about it.
The family member who made the original call, identified in inspection records only as V6, had done what families are supposed to do. They noticed something, named it specifically, and contacted the facility. Mold, rust, and "a bunch of stuff." That call reached a staff member, who relayed it to the administrator. And somewhere in that chain, it stopped moving, undocumented and unresolved, until an inspector walked through the door.
Three water heaters, three hallways, residents living in rooms where the closets hold equipment coated in mold and rust. The maintenance director was said to be working on replacements. Whether the family member who first raised the alarm was ever told what happened to the concern they called in, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shelbyville Manor from 2025-11-16 including all violations, facility responses, and corrective action plans.
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 1, 2026 · Our methodology
SHELBYVILLE MANOR in SHELBYVILLE, IL was cited for violations during a health inspection on November 16, 2025.
That sequence of events came to light during a November 16 complaint inspection at Shelbyville Manor, a nursing home in Shelbyville, Illinois.
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.