Shelbyville Manor
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
facility does not document the resident's 15-minute checks that would mean the facility cannot prove that any of those residents' interventions were in place prior to any fall. V2 DON stated the facility is going to ‘look at this system' to see how that can be rectified. V2 DON stated she has witnessed the staff caring for residents who have an alternate call light system but cannot say that the 15-minute check was completed every time due to lack of documentation. On 11/16/25 at 2:30 PM, V1 Administrator stated the facility does not keep separate files for fall investigations. V1 stated the only time a paper component would be available would be for a resident's fall that had to be reported to the State Agency. V1 Administrator stated whatever is in the Electronic Medical Record (EMR) is all that the facility would be able to provide. V1 Administrator stated the facility does not have a policy on staff documenting cares. V1 Administrator stated the expectation is for the staff to follow the care plan for each resident. The facility policy titled Call System (Alternate) revised April 2021 documents all residents that are unable to use a call light system will be provided with an alternate source of monitoring for needed assistance.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shelbyville Manor
1111 West North 12th Street Shelbyville, IL 62565
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0921
F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
risk to the residents are being replaced first. On 11/16/25 at 11:10 AM, V7 CPC stated V6 (Resident R1) Power of Attorney (POA) called V7 to inquire about a water heater in Resident R1's room having 'mold, rust and a bunch of stuff' all over it. V7 CPC stated she reported this to V1 Administrator in the next day's morning meeting. V7 CPC stated I don't know whatever was done with that, but I reported it to (V1). That was (V1's) responsibility then, not mine. V7 CPC stated there was no progress note made about this concern. V7 CPC stated she did not remember what date V6 called her. On 11/16/25 at 2:30 PM, V1 Administrator stated the facility has ‘several' hot water heaters that are located in closets in resident rooms on three different hallways. V1 stated she was ‘just made aware' that three of those water heaters had ‘mold, mildew and rust'
on them that could cause a potential health risk to a resident. V1 Administrator stated the water heaters ‘probably' don't get hot enough to cause a fire hazard but also should not have ‘mold, mildew and rust' on them within the resident areas. V1 Administrator stated V16 Maintenance Director is working to get them replaced.
Event ID:
Facility ID:
If continuation sheet
SHELBYVILLE MANOR in SHELBYVILLE, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SHELBYVILLE, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SHELBYVILLE MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.