The citation, recorded under F0744, covers a cluster of failures that inspectors found working together.
Nursing Home News — Page 379
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The admission came during a November 2025 complaint inspection by federal surveyors.
Inspectors who arrived at the facility on November 23, 2025, documented exactly that problem.
The inspection, completed in November 2025, was triggered by a complaint.
Inspectors classified it as an isolated deficiency with no documented harm but with the potential for more than minimal harm to residents.
The violation was cited at F0689, the federal tag covering accidents and supervision, and was classified as causing actual harm to at least one resident.
That sequence of events came to light during a November 16 complaint inspection at Shelbyville Manor, a nursing home in Shelbyville, Illinois.
It is not a paperwork violation.
The finding centered on a single nurse, identified in inspection records only as Staff D, and a single resident, identified as Resident 1.
The violation was cited under F0880, the federal tag covering infection prevention and control.
A finding of potential for more than minimal harm means inspectors judged the problem serious enough that it could hurt someone, even if it hadn't yet.
The finding at The Gardens of El Monte was one of two deficiencies cited during the November 14 inspection.