Shelbyville Manor
SHELBYVILLE MANOR in SHELBYVILLE, IL — inspection on October 23, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
- V5 stated R1 has always had body pillows in place while in bed and if R1 is not in bed, R1 is to be up
at the nursing station for closer supervision. V5 stated, R1 transfers with one assist. V5 stated R1 requires frequent visual checks because R1 likes to get out of bed and ambulate throughout the day and night. V5 stated R1 falls frequently because she is unsteady and requires assistance with walking. V5 stated that body pillows are to be placed under the sheet to keep R1 from getting up and walking by herself.
When asked about R1's care plan, V5 looked at R1's electronic health record and stated R1's care plan does not include the use of the body pillow. V5 also stated R1's record did not contain an assessment for the use of the body pillows on R1's bed. On 10/21/2025 at 11:17AM V7 Licensed Practical Nurse (LPN) stated, R1 likes to get up by herself and the body pillows that are on each side of the bed are to prevent falls. V7 stated there is no assessment for the body pillows in the chart or care plan but staff were told by the facility to keep the body pillows on while R1 was in bed.On 10/21/2025 at 12:30PM, V11 Registered Nurse stated, If (R1) is determined she will find a way out of her bed as she is a high-risk faller.On 10/21/2025 at 12:56 PM, V2 Director of Nursing stated the body pillows are used to prevent R1 from getting out of the bed. V2 stated a restraint assessment should have been completed for the use of the body pillows and reassessed after each fall. At that time, V2 looked at R1's electronic medical record and confirmed there were no restraint assessments in the medical record and no interventions on the care plan related to the use of the full-length body pillows. V2 stated that the fracture was related to the fall on 10/10/25 and the body pillows were in place on R1's bed before the fall. On 10/21/2025 at 12:45 PM, V8 (R1's Hospice Nurse Practitioner) stated using the full body pillows on top of a concave mattress puts R1 at a greater risk for injury as it creates an extra obstacle for R1 to get out of bed. V8 stated R1 is at greater risk for falls and injury due to cognitive impairment, ambulatory, and receiving pain medication.
The Facility's Restraint Policy with a revision date of 11/2017 documents restraints will not be used to restrict a resident's freedom of movement.
This policy documents using a concave mattress to prevent a resident from getting out of bed as an example of a physical restraint.
This policy documents that an assessment will be completed prior to the use of the restraint, and a reassessment will be completed every 90 days.
The facility will assess for restraints with each resident to attain or maintain his/her highest practicable well-being in the least restrictive environment while preventing injury.
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