Shell Lake Health Care Center

In the surveyor’s words

From the most serious findings on record at Shell Lake Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 10, 2025

  Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This had the potential to affect all 35 of the 37 residents who consume food or beverages from the facility's kitchen. Facility staff did not wear a hair net in the kitchen.Dietary staff did not check food temperatures on cold beverages before serving to residents.The facility's policy and procedures titled, Standards for Dress and Cleanliness, reads in part, .Hair nets, covering all hair, will be worn by all Food Service employees at all times.The facility's policy titled, Food Temperature Maintenance, dated 1/2007, states in part, .Cold Food Items. […]

• No harm, potential for more than minimal, widespreadF812Jun 28, 2023

  Based on observation, interview and record review, the facility did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service for all 42 residents. Dishwasher temperature logs were not complete. Staff touching ready to eat foods with contaminated gloves. Findings include: On 06/26/23 at 9:30 AM, during initial tour of the kitchen with Dietary Manager (DM) G, Surveyor noted the dishwasher temperature log was missing temperature recordings on June 17, 20, 24, 25 and 26th. Surveyor asked for temperature logs for both April and May. DM G led surveyor to the office. […]

• No harm, potential for more than minimal, widespreadF880Jun 28, 2023

  Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection. This had the potential to affect 34 of 42 residents. Staff did not perform proper hand hygiene for residents prior to meals for 34 of 42 residents. The facility staff did not do proper glove changes with hand washing while performing resident cares for R9. Certified Nursing Assistant (CNA) C used Alcohol Based Hand Rub (ABHR) to clean hands while providing cares for Resident (R) 33 who has a diagnosis of Clostridium Difficile (C-Diff is a highly contagious bacterium that causes diarrhea). Example 1: On 6/26/23 at approximately 12 p.m. […]

• No harm, potential for more than minimal, widespreadF812May 5, 2021

  Based on observation, record review and interviews, the facility did not prepare and serve food in accordance with standards for food service safety. The facility did not check the food temperatures of foods prior to serving. This has the potential to affect all 32 residents. This is evidenced by: During the initial kitchen tour that started on 05/03/21 at 9:30 a.m., Surveyor reviewed random Meal Serving Temperatures logs and noted there were no recorded food temperatures for the evening meal. On 05/04/21 at 7:40 a.m., Surveyor observed Cook-F check food temperatures for the breakfast meal. Cook-F documented food temperatures and properly cleaned the thermometer between food items. Cook-F stated food temperatures were checked prior to serving all food items. […]

• No harm, potential for more than minimal, isolatedF605Aug 19, 2026

  Based on interview and record review, the facility did not ensure each resident's drug regimen is free from unnecessary drugs for 1 of 5 residents reviewed for unnecessary medications (R2) out of a sample of 16 residents.-The facility nurse transcribed R2's order as Diazepam 2mg tablet. Take 0.5 tablet twice a day, instead of take 0.5mg tablet twice a day as needed (PRN). R2 received a total of 9 doses of Diazepam.Findings include:The facility policy with a subject titled, Transcription of Physician Orders, last revised 06/2018, includes: Nurse will initiate a transcription check list for all new orders. Nurse taking order will follow and complete areas on the transcription check list.Nurse will make a copy of the order and staple to the transcription check list. […]