Shell Lake Health Care Center

Inspectors wroteBased on record review, facility document, policy review and interviews, the facility failed to ensure allegations of physical abuse by a staff member against two of five residents (Resident (R)1 and R2) reviewed for abuse were reported immediately for timely follow up and prevention of further potential abuse and failed to submit the five-day follow up investigation report to the State Agency in a timely manner. These failures had the potential to lead to further physical abuse of residents.

Inspectors wroteBased 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. Cold liquids should be served at 41 degrees or cooler The Food and Drug Code requires cold food at 41 degrees or below . [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 12 residents (R) (R11) reviewed. R11's nutrition assessments required for quarterly Minimum Data Set (MDS) assessment were not completed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 3 residents (R), R7 and R11, reviewed. R7 had multiple falls; the facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall and review and revise care plan fall interventions. R11 fell on 5/25/25. New intervention to encourage resident to sleep in R11's own bed was documented to be implemented. New intervention not in care plan or on Certified Nursing Assistant (CNA) plan of care/kardex. This is evidenced by: Example 1 Facility policy titled, Falls-Incident Reports-Fall Prevention, with a revised date of 12/2018, states in part: POLICY: [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 4 residents (R)(R27) reviewed for pain management. R27's care plan did not include resident's desired/tolerable pain level and pain assessments did not include characteristics, location, and duration to determine effectiveness of intervention or worsening of pain. This is evidenced by:Facility policy titled, Pain Management and Assessment, with a revised date of 06/2018, states in part: PURPOSE: To promote and prioritize the recognition, assessment, treatment and monitoring of pain. POLICY: To promote a systematic interdisciplinary and individualized approach to pain management. Pain will be reviewed by Nursing with the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, administering, storage, and disposal of all drugs and biologicals. Licensed Practical Nurse (LPN) C administered an insulin dose without prior priming of the insulin pen for 1 out of 2 residents (R34) observed for insulin administration.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary medications for 1 of 6 residents (R) (R4) reviewed. R4 was prescribed an antidepressant without adequate indication for use. This is evidenced by:Facility policy titled, Psychotropic Medications, with an effective date of 08/2021, states in part: POLICY: To review psychotropic medications for correlating diagnosis, appropriateness and reduction. To ensure that each residents medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. 5. The resident Plan of Care shall address specific behaviors and interventions. 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This affected 2 of 2 residents (R) reviewed for infection control (R2, R9) Certified Nursing Assistant (CNA) F did not practice proper hand hygiene during cares for R2. Environmental Manager (EM) D was in a R9's room and did not cover nose or mouth while sneezing and did not wipe down the surface prior to leaving the room.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures when staff did not report an incident of caregiver neglect to the administrator immediately for 1 of 3 residents (R) reviewed for abuse and neglect. (R20)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide the necessary services for 2 of 6 sampled and supplemental sampled residents (R9, R4) to maintain good grooming, toileting and personal hygiene. This is evidenced by: The facility policy and procedure titled General Care For All Residents includes the following directives to staff: - The resident shall be kept clean and dry - Staff will respond to call lights timely Example 1 R9 has medical diagnoses that include but are not limited to, diabetes mellitus type 2, a recent cerebral infarction (3/6/24), unspecified depression and dementia. According to the most recent MDSA (Minimum Data Set Assessment), which was a Significant Change in Status Assessment with an Assessment Reference Date of 3/18/24, R9 has impaired short-term and long-term memory and severely impaired daily decision making abilities. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure 3 of 3 residents reviewed for high risk of pressure injury (PI) development (R9, R5 and R27), received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R9 has an active pressure related deep tissue injury to the right heel. R9 remains a high risk for the development of additional PIs related to immobility and bowel and bladder incontinence. An observation of 4 hours 41 minutes was conducted in which repositioning was not offered. Once staff did assist R9 onto the bed for incontinence care, R9's buttocks was red and wrinkled from no pressure redistribution and the incontinence of urine and feces. - R5 is a high risk for PI and has a current PI on the scapula. [...]

Inspectors wroteBased on observation, interview and record review, 2 of 3 residents (R20 and R27) at risk for falls did not receive adequate supervision and assistance devices to prevent accidents. R20 required the assistance of 2 staff for transfers. CNA M transferred R20 with one person and R20 fell. R27 was at risk for falls. R27's fall interventions included wearing a knee immobilizer to the right knee during all transfers for stability. CNA G was observed transferring R27 from the wheelchair to the bed without using R27's knee immobilizer.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice for 1 of 1 resident (R) reviewed for respiratory care. (R6) The facility did not clean oxygen filter, change nasal cannula tubing, and ensure R6 received oxygen at the ordered rate according to physician orders. This is evidenced by: R6 was admitted to the facility on [DATE] and has diagnoses that include acute and chronic COPD, congestive heart failure, stroke, stage 5 kidney disease, and is receiving hospice services. On 06/18/24 and 06/19/24, Surveyor observed R6 using oxygen via nasal cannula continuously via a black oxygen concentrator set at 2 liters per minute. Surveyor interviewed R6 on 06/18/24 at 10:17 AM. [...]

Inspectors wroteExample 2 R9 has an active pressure related deep tissue injury to the right heel. R9 remains a high risk for the development of additional PIs related to comorbidities as well as immobility and bowel and bladder incontinence. On 6/19/24, a continuous observation of 4 hours 41 minutes was conducted (7:18 AM - 11:59 AM) in which toileting and repositioning was not offered. Once staff did assist R9 onto the bed for incontinence care, R9's buttocks was red and wrinkled from no pressure redistribution and the incontinence of urine and feces. Interviews were conducted with staff in which they indicated staffing was insufficient on that day, with three new and one seasoned Certified Nursing Assistant working the two halls in which residents reside. Please refer to F677 and F686 for details. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure proper infection control practices were followed during and after resident care. This occurred for 1 of 1 resident (R)1.

Inspectors wroteBased 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.

Inspectors wroteBased 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. during the lunch meal, Surveyors observed the main dining area. All residents eat meals, except for one resident who is tube fed. [...]

Inspectors wroteBased on observation, interview and record review the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs for a resident with weight loss. This occurred for 1 of 3 residents (R) reviewed for nutrition. (R16) R16 was assessed at nutritional risk on admission and had a 7.37% weight loss in one month. R16's comprehensive care plan did not include problems, goals, or interventions to address nutrition.