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 25 of 27 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 26 of 27 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46693 potential for actual harm Based on observation, interview and record review, the facility did not provide a sanitary environment to help Residents Affected - Few 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.

Findings include:

Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses that include dementia, cerebral palsy, stroke, type 2 diabetes, epilepsy, and left sided paralysis. Resident R1's Minimum Data Set (MDS), dated [DATE REDACTED], indicates Resident R1 had

a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Resident R1's care plan identifies that Resident R1 is unable to walk and requires 2 assist for bed mobility, transfers, and toileting. Resident R1 uses a broda chair and a hoyer lift.

On 06/19/24 at 7:36 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D provide pericare for Resident R1.

CNA D provided the peri care, doffed gloves and did not sanitize hands and proceeded to grab hoyer sling, placed under Resident R1, pushed curtain back, grabbed hoyer, attached sling, raised Resident R1 up, placed Resident R1 in a broda chair, donned gloves again, then grabbed Resident R1's dentures. Surveyor stopped CNA D due to failure to sanitize hands after removing gloves following pericare.

Surveyor asked CNA D if she forgot anything. CNA D stated she was not sure. Surveyor stated that CNA D should have sanitized her hands after doffing gloves from doing pericare and applying new gloves to then provide Resident R1 denture care.

CNA C discarded the soiled water from the wash basin in the sink with Resident R1's denture cup present. Surveyor asked CNA C if it is common practice to discard the soiled water in the sink. CNA C stated she did not know that was a rule and apologized.

On 06/19/24 at 8:50 AM, Surveyor interviewed DON B and was asked what the expectation would be for hand hygiene following doffing gloves and where dirty wash basin water should be discarded after use. DON B replied that hand hygiene should be completed every time after doffing gloves and basins should be emptied in the toilet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 525553