Shell Lake Health Care Center

F-F686 for details.

48793

Example 3

Resident R2 was admitted to the facility on [DATE REDACTED]. Diagnoses included Alzheimer's disease, dementia, heart failure, anemia, and hypertension.

Minimum Data Set (MDS) assessment dated [DATE REDACTED] confirmed Resident R2 scored 03/15 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Resident R2's MDS assessment reported Resident R2 is frequently incontinent of urine and always incontinent of bowel. Resident R2 required substantial assistance with toileting, showering, and dressing, and was dependent on staff for transfers.

The follow occurred on 06/19/24 during a continuous observation from 1:05 PM-2:14 PM, for 1 hour and 9 minutes. Surveyor observed four facility staff members (Director of Nursing, two licensed nursing staff, and Activities Director) walk by Resident R2's call light.

On 06/19/24 at 1:05 PM, Surveyor observed Resident R2's call light on when ambulating down the hallway. Surveyor observed CNA G walk past Resident R2's call light and enter another resident room.

On 06/19/24 at 1:06 PM, Surveyor entered into Resident R2's room and asked how Resident R2 was. Resident R2 indicated that Resident R2 had to use the bathroom badly and wanted to get into bed as Resident R2 was tired.

On 06/19/24 at 1:25 PM, Surveyor observed Resident R2's call light still on. Surveyor observed CNA J walk by Resident R2's room.

On 06/19/24 at 1:41 PM, Surveyor observed Resident R2's call light still on. Surveyor observed Activities Director E walk by Resident R2's room.

On 06/19/24 at 1:59 PM, Surveyor observed Resident R2's call light still on. Surveyor observed DON B enter Resident R2's room and ask Resident R2 what Resident R2's needs were. Resident R2 indicated that Resident R2 had to use the bathroom and get into bed. DON B turned the call light off and indicated that DON B would let a staff member know that Resident R2 needed assistance in Resident R2's room. Surveyor observed DON B exit Resident R2's room and walk down the hallway.

On 06/19/24 at 2:02 PM, Surveyor observed Resident R2's call light go on again.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 525553 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525553 B. Wing 06/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shell Lake Health Care Center 802 E Cty Hwy B Shell Lake, WI 54871

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 06/19/24 at 2:14 PM, Surveyor observed CNA G entering Resident R2's room. Surveyor interviewed CNA G and asked if DON B had informed CNA G that Resident R2 needed assistance. CNA G indicated no DON B did not let Level of Harm - Minimal harm or CNA G know of Resident R2's need. CNA G indicated that CNA G now had time to answer Resident R2's call light. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 525553