Shell Rock Senior Living

In the surveyor’s words

From the most serious findings on record at Shell Rock Senior Living, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Jul 19, 2024

  Based on observation, record review, resident interview, staff interview, facility kitchen photos, and facility policy review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure the kitchen had working equipment to clean the dishes, such as a dishwasher and garbage disposal. The dishwasher failed to release the required chemicals used to clean the dishes. The sink used for the garbage disposal had standing debris filled water. The tour of the kitchen revealed multiple items covered in dirt, dust, and debris. The kitchen had undated and open items. The meal planned for that evening's dinner had flies landing on the food. […]

• Immediate jeopardy, isolatedF760Mar 28, 2022

  Based on observations, record reviews, policy review and staff interviews, the facility failed to ensure that residents were free of significant medication errors, specifically the facility failed to accurately transcribe a PT/INR (coagulation) laboratory order for 1 of 3 residents reviewed (Resident #1) on anticoagulation therapy. As a result Resident #1's INR was not monitored as ordered, resulting in Resident #1 having increased confusion, fatigue, slurred speech, and required an ambulance transfer to the local emergency room . Resident #1 required treatment at the local emergency room with an INR at critical levels (>15). Additionally, the facility failed to accurately transcribe an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 after her discharge from the hospital. […]

• Actual harm, isolatedF689May 9, 2024

  Based on observation, clinical record review, interviews, facility policy, and investigation review, the facility failed to ensure staff provided a safe transfer with a mechanical lift for 1 of 4 residents reviewed that required transfer assistance (Resident #1). Resident #1 sustained a fall on 2/19/24 from a mechanical lift transfer when the mechanical lift sling strap came undone resulting in Resident #1 falling to the floor feet first, striking their head, and receiving a left subtrochanteric femoral fracture (hip fracture). The facility reported a census of 34 residents. Finding include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired decision-making abilities. […]

• Actual harm, isolatedF689Mar 28, 2022

  Based on observations, clinical record reviews, staff interviews, and facility policy review, the facility failed to ensure staff provided a safe transfer with a mechanical lift for 1 of 5 resident's reviewed (Resident #4) that required transfer assistance. Resident #4 sustained a fall on [DATE] during a mechanical lift transfer when the mechanical lift sling strap was not properly fastened causing the strap to slip off during the transfer which resulted in the resident falling to the floor head first, striking her head and resulting in a raised area on her head. The facility reported a census of 41 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented she had severe impaired cognitive skills. […]

• No harm, potential for more than minimal, widespreadF812Sep 4, 2025

  Based on observation, staff interviews, and policy review the facility failed to clean the kitchen convection oven and handwashing sink. In addition, the facility failed to ensure staff wore hairnets and didn't touch food with their contaminated gloved hands. The facility reported a census of 34 residents. Findings include: During an initial kitchen walk through on 9/2/25 at 9:18 AM observed the white hand washing sink had a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches. In addition, the convection oven had a brown-like sticky discoloration on the inside and the outside of the doors, throughout the inside of the oven and on the metal racks. […]