Shell Rock Senior Living
Shell Rock Senior Living in Shell Rock, IA — inspection on September 4, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited Shell Rock Senior Living in Shell Rock, IA for a deficiency under regulatory tag F-F0637 during a standard health inspection conducted on 2025-09-04.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Assess the resident when there is a significant change in condition
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of Shell Rock Senior Living.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-22.
Federal health inspectors cited Shell Rock Senior Living in Shell Rock, IA for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-09-04.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of Shell Rock Senior Living.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-22.
Federal health inspectors cited Shell Rock Senior Living in Shell Rock, IA for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-09-04.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Post nurse staffing information every day.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of Shell Rock Senior Living.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-22.
Based 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.
Findings include:The facility's menu for the noon meal on 9/3/25 titled, Week 2 Wednesday, dated 5/14/25 instructed to provide 8 oz. of chicken and pasta alfredo.
During an observation of the noon meal service on 9/3/25 from 11:55 AM to 12:55 AM, Staff D, Cook, used a 6 oz. scoop instead of an 8 oz. scoop as the menu directed for serving 32 servings of chicken and pasta alfredo.
During an interview on 9/3/25 at 12:53 PM the Dietary Manager reported they provided a heaping 6 oz. scoop of the chicken and pasta alfredo to all residents instead of using an 8 oz. scoop as they didn't have 8 oz scoops in the facility and needed to order more.
She explained she told Staff D he should use 2, four (4) oz. scoops, but he didn't.
During an interview on 9/3/25 at 12:55 PM Staff D said he used a 6 oz. scoop of chicken and pasta alfredo instead of the 8 oz. scoop as the facility didn't have any 8 oz. scoops.
During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) stated she expected all residents get the intended scoop size of the chicken and pasta alfredo.
She added if the facility didn't have an 8 oz. scoop, they should have placed an order to get new ones.
During an interview on 9/4/25 at 10:37 AM the Administrator reported she expected the staff to follow the menu and use the scoop size as directed.
The facility's undated Select Menu policy lacked direction to use the proper scoop sizes.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Shell Rock Senior Living
920 North Cherry Street Shell Rock, IA 50670
SUMMARY STATEMENT OF DEFICIENCIES
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. An observation of the Dietary Manager wearing a baseball cap without a hair net, and the hair appeared over one inch in length protruding out below the baseball cap.
During a follow-up walk through observation on 9/3/25 at 11:56 AM the hand washing sink continued to have a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches.
The convection oven also continued to have a brown sticky-like discoloration on the inside and outside of the doors and throughout the inside of the oven and on the metal racks.
During an observation on 9/3/25 at 11:59 AM the Dietary Manager held a cool whip container with a gloved hand and a spatula with another gloved hand. As she scooped out the cool whip onto the dessert to serve, she took the gloved hand holding the cool whip container and used her index finger to scrape off the spatula to get the whip cream to cover dessert.
During the observation, she continued to wear a baseball cap without a hairnet.
During an observation of the noon meal service on 9/3/25 from 11:55 AM to 12:55 AM while wearing gloves, Staff D, Cook, touched the diet name cards, serving utensils, plates, and transportation carts.
Staff D proceeded to grab the garlic bread and place one on each residents' plate with the same gloved hands.
Staff D served approximately 32 servings of garlic bread with contaminated gloves
During an interview on 9/3/25 at 12:55 PM Staff D revealed he didn't use tongs during meal service and instead grabbed each piece of garlic bread and set them on the plates with his gloved hands. He explained as long as he had gloves on, he didn't need to use a tongs to touch the bread.
During an interview on 9/3/25 at 2:45 PM the Infection Preventionist said she hadn't completed audits on the kitchen practices.
During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) reported she didn't know why Staff D wore gloves during 9/3/25 noon meal service, as that isn't their normal routine.
She expected them to use tongs to place the bread on the plates.
During an interview on 9/4/25 at 10:37 AM the Administrator revealed she would expect the Dietary Manager to wear a hairnet and not just a baseball cap.
She also informed Staff D during the 9/3/25 noon meal service does not normally wear gloves as that is not their normal routine and practice and believe it was due to being nervous, and food should not be touched with contaminated gloves.
The facility's undated General Food Preparation and Handling policy directed the following: a.
Clean and sanitize the kitchen surfaces and equipment as appropriate. b.
Disposable gloves are single use item and should be discarded after each use.
Employees should wash hands prior to putting gloves on and after removing gloves. c.
Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact with prepared foods. d.
Use tongs or other servings utensils to serve breads or other items to avoid bare hand contact with food
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Shell Rock Senior Living
920 North Cherry Street Shell Rock, IA 50670
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited Shell Rock Senior Living in Shell Rock, IA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-04.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of Shell Rock Senior Living.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-22.
Based 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.
Findings include: During an observation on 9/3/25 at 12:08 PM a fly landed on two (2) bowls of crushed pineapple, then flew over, and landed on pureed peas.
The kitchen had (4) flies present during the observation in the kitchen and one (1) dead fly noted on a cupboard door from 11:55 AM to 12:55 AM.
During an interview on 9/3/25 at 2:45 PM the Infection Preventionist reported she hadn't completed audits on practices in the kitchen.
During an interview on 9/4/25 at 10:37 AM with the Administrator explained the facility had bug traps but didn't know when pest control last came to the facility.
She reported flies shouldn't land on the food during food service.
Review of the facility's undated General Food Preparation and Handling policy instructed to prepare food items to conserve maximum nutritive value, develop, enhance flavor, and keep free of harmful organisms and substances.
Review of the facility's undated policy Pest Control Program directed the facility to use a variety of methods to control certain seasonal pests, i.e. (example) flies.
The program would involve indoor and outdoor methods deemed appropriate by the outside pest service, state and Federal regulations.
Facility ID: