C
WILLOWS OF SHELBYVILLE
55/100 score
0.46 hrs RN staffing
5 deficiencies
ASHFORD PLACE HEALTH CAMPUS
2200 N RILEY HWY, SHELBYVILLE, IN 46176
B
Facility Assessment
Inspectors recorded 2 citations at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — above average inspection record.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.54 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
26
Outstanding
0
Actual harm or worse (G–L)
2
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★★★ (5/5)
Staffing: ★★★☆☆ (3/5)
|
|
NursingHomeGrade Score
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66/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
1 immediate jeopardy, 1 actual harm issues found among 26 total deficiencies. 26 corrected.
Most recent inspection (August 13, 2025)
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2025
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2025
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2025
D
Potential harm — isolated
F0644
Status: Corrected
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2025
Inspection cycle 2 (May 1, 2024)
D
Potential harm — isolated
F0770
Status: Corrected
Provide timely, quality laboratory services/tests to meet the needs of residents.
Administration Deficiencies — Deficient, Provider has date of correction, corrected May 17, 2024
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 17, 2024
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 17, 2024
D
Potential harm — isolated
F0761
Status: Corrected
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 17, 2024
G
Actual harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024
D
Potential harm — isolated
F0657
Status: Corrected
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 17, 2024
D
Potential harm — isolated
F0622
Status: Corrected
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 17, 2024
D
Potential harm — isolated
F0585
Status: Corrected
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 17, 2024
Inspection cycle 3 (January 11, 2023)
D
Potential harm — isolated
F0867
Status: Corrected
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
J
Immediate jeopardy — isolated
F0600
Status: Corrected
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2023
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2023
D
Potential harm — isolated
F0881
Status: Corrected
Implement a program that monitors antibiotic use.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0886
Status: Corrected
Perform COVID19 testing on residents and staff.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0791
Status: Corrected
Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0657
Status: Corrected
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 8, 2023
D
Potential harm — isolated
F0554
Status: Corrected
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2023
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D
ESPECIALLY KIDZ HEALTH & REHAB
48/100 score
0.43 hrs RN staffing
7 deficiencies
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