Willows of Shelbyville
2309 S Miller St, Shelbyville, IN 46176
Willows of Shelbyville is a nursing home in Shelbyville, Indiana. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionDecember 23, 2025 (10 months ago)
- Health citations since July 26, 202330 (Indiana average 23)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 25, 2026
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on December 23, 2025
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 21, 2026.
CMS has cited this home for F0656 2 times since 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on January 21, 2026.
CMS has cited this home for F0692 2 times since 2023.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on January 21, 2026.
CMS has cited this home for F0744 3 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 21, 2026.
CMS has cited this home for F0880 3 times since 2023.
Fire safety inspection on December 23, 2025
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on April 1, 2026.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on April 1, 2026.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 1, 2026.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on April 1, 2026.
CMS has cited this home for K0293 2 times since 2024.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 1, 2026.
CMS has cited this home for K0324 2 times since 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on April 1, 2026.
CMS has cited this home for K0372 2 times since 2023.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on April 1, 2026.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 1, 2026.
CMS has cited this home for K0511 2 times since 2023.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS has cited this home for K0521 3 times since 2023.
Citation K0522. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an externally vented heating system.
CMS lists it as corrected on April 1, 2026.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on April 1, 2026.
Citation E0039. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on April 1, 2026.
CMS update of May 28, 2025
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Health inspection on March 6, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 20, 2025.
CMS has cited this home for F0812 2 times since 2024.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on October 1, 2024
7 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 7 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 25, 2024.
Citation F0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on October 25, 2024.
Citation F0744. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on October 25, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on October 25, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on October 25, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on October 25, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 25, 2024.
Fire safety inspection on October 1, 2024
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on November 8, 2024.
CMS has cited this home for K0222 2 times since 2023.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on November 8, 2024.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on November 8, 2024.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on November 8, 2024.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 8, 2024.
CMS has cited this home for K0321 2 times since 2023.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on November 8, 2024.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on November 8, 2024.
CMS has cited this home for K0351 2 times since 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on November 8, 2024.
CMS has cited this home for K0363 2 times since 2023.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on November 8, 2024.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 8, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of May 29, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Health inspection on May 2, 2024
3 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
63 of 507 Indiana homes (12%) got a citation at the actual harm level in 2024.
Show the 3 citations
Citation F0740. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on May 20, 2024.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on May 20, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 20, 2024.
Health inspection on February 22, 2024
5 citationsCMS lists this as a complaint inspection.
Show the 5 citations
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on March 20, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on March 20, 2024.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on March 20, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 20, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 20, 2024.
CMS update of December 21, 2023
Fire safety citation
CMS removed citation K0211 from the fire safety inspection on August 14, 2023.
Health inspection on July 26, 2023
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on August 25, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on August 25, 2023.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on August 25, 2023.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 25, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on August 25, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on August 25, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 25, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on August 25, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on August 25, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 25, 2023.
Fire safety inspection on July 26, 2023
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation E0031. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on October 31, 2023.
Citation E0037. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on October 31, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on October 31, 2023.
Citation K0351. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on October 31, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 31, 2023.
Citation K0200. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on October 31, 2023.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on October 31, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on October 31, 2023.
Citation K0361. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
CMS lists it as corrected on October 31, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on October 31, 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on October 31, 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 31, 2023.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on October 31, 2023.
Citation E0025. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Create arrangements with other facilities to receive patients.
CMS lists it as corrected on October 31, 2023.
Citation E0030. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on October 31, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (317) 398-9781
- Last standard health inspection
- December 23, 2025 (10 months ago)
- Certified beds
- 121
- Residents per day, on average
- 91.2
- Ownership type
- Government - City/county
- Legal business name
- Major Hospital
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Indiana average (30 vs 23).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- SHELBYVILLE IN OPCO LLCOperational/managerial control · not applicable · since 07/01/2023
- CLAXTON, RYANOperational/managerial control · not applicable · since 03/27/2025
- FRANKEL, ISRAELOperational/managerial control · not applicable · since 07/01/2023
- PAUL, MANDIOperational/managerial control · not applicable · since 04/01/2024
- RADADIYA, PRAGNESHKUMAROperational/managerial control · not applicable · since 07/01/2023
Questions
When was Willows of Shelbyville last inspected?
CMS lists December 23, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Willows of Shelbyville have?
CMS lists 30 health citations since July 26, 2023. CMS also calls these deficiencies.
Has Willows of Shelbyville been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Willows of Shelbyville?
Its CMS overall star rating is 2 of 5.
Is Willows of Shelbyville a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.