Shell Rock Senior Living

Inspectors wroteBased 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.

Inspectors wroteBased on observation and staff interviews the facility failed to post daily staffing in a visible place for all visitors and residents to see. The facility reported a census of 34 residents.

Inspectors wroteBased on record review, observation, staff interview, and policy review the facility failed to provide the correct portion size of 8 ounce (oz.) of chicken and pasta alfredo for 32 of 34 residents during a meal observation on 9/3/25 at the noon meal service. The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, observation, policy review, and staff interviews, the facility failed to have a separate entrance and exit for clean and dirty laundry into the laundry room. In addition, the facility failed to use proper infection control practices when staff touched resident medication with their bare hand prior to medication administration. The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to complete a significant change in condition assessment for 1 of 1 residents admitted to hospice care services (Resident #23). The facility identified a census of 34 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to identify a weight loss and notify the primary care provider (PCP), dietitian, and/or family for 1 or 2 residents (Resident #3) reviewed for weight loss. The facility identified a census of 34 residents.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to keep flies off the food prior to serving. The facility reported a census of 34 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to have a full time (40 hours a week) Director of Nursing (DON) at the facility. In addition, the facility failed to have eight (8) hours of consecutive Registered Nurse (RN) coverage a day for 4 of 30 days reviewed. The facility reported a census of 34 residents.

Inspectors wroteBased on observation, policy review, staff, and resident interview, the facility failed to find or replace 1 of 1 resident (Resident #25) hearing aides when they identified them missing. The facility reported a census of 34 residents.

Inspectors wroteBased on observation, record review, resident and staff interviews the facility failed to provide routine repositioning for 1 of 3 residents (Resident #19). The facility reported a census of 34 residents.

Inspectors wroteBased on record review and staff interview the facility failed to code the Minimum Data Set (MDS) to reflect 1 of 2 residents (Resident #1) reviewed for hospice was receiving hospice services. The facility reported a census of 34 residents.

Inspectors wroteBased 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. In addition, the kitchen had spiderwebs and mold in the kitchen. [...]

Inspectors wroteBased on observation, record review, staff, and resident interview the facility failed to maintain and promote resident's dignity while serving meals for 3 of 3 residents reviewed (Residents #1, #2 and #3). The facility identified a census of 33 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, observations, staff interviews, and policy review the facility failed to keep kitchen equipment clean and sanitary for 32 of 32 residents that receive meals from the kitchen. The facility reported a census of 32 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code Minimum Data Set (MDS) Assessments when they inaccurately coded 1 of 1 residents Preadmission Screening and Resident Review (PASRR) (Resident #1), 1 of 1 residents use of anti-coagulant (blood thinner) medication (Resident #20), and 1 of 2 residents Hospice status on two different MDS assessments (Resident #8). The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to provide an assessment and implement interventions based on that assessment for 1 of 1 resident reviewed for falls (Resident #13). The facility reported a census of 32 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to complete assessments for 1 of 1 residents before and after dialysis treatments received at a certified dialysis facility (Resident #34). The facility reported a census of 32 Residents.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to provide 3 of 37 medications as ordered by the provider. The facility reported a census of 32 residents.

Inspectors wroteBased on staff interviews and policy review the facility failed to have a qualified professional serve as the Dietary Manager. The facility reported a census of 32 residents.

Inspectors wroteBased on observation and staff interview the facility failed to cover 6 of 6 garbage cans in the kitchen. The facility reported a census of 32 residents.

Inspectors wroteBased on record review, e-mail correspondence, and policy review the facility failed to have documentation for 1 of 3 quarterly Quality Assurance (QA) meetings for the calendar year of 2023. The facility reported a census of 32 residents.