Shell Lake Health Care Center
SHELL LAKE HEALTH CARE CENTER in SHELL LAKE, WI — inspection on December 23, 2025.
Found 1 citation. 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
During an interview on 12/22/25 at 2:49 PM, the DON stated the allegations of abuse by CNA2 against R1 and R2 were not substantiated.
The DON stated education was done with all staff to report any potential allegation immediately.
The DON stated CNA1 received this education but terminated her employment before working again.
The DON stated she expected staff to report any allegation immediately to their supervisor or to administration to ensure the alleged perpetrator was removed from the floor right away in order to prevent further potential abuse.During a telephone interview on 12/22/25 at 3:03 PM, CNA1 stated on 08/23/25, she heard R1 shouting from behind a closed door and heard a thud in the room while CNA2 was providing care.
She also stated she overheard R2 saying, quit being so rough to CNA2 while CNA2 was assisting her with dressing. CNA1 stated she did not report her concerns until she came back to work on her next shift, which was 08/25/25. CNA2 stated since there was nobody around at the time to report to at the end of her shift on 08/23/25, she could not report her concerns that night.During a telephone interview on 12/22/25 at 3:24 PM, the Administrator stated CNA1 had been educated on the facility's abuse policy upon hire and reeducation was provided to all staff after this incident.
The Administrator stated CNA1 was not exactly sure if what she witnessed constituted potential abuse and therefore she did not report right away; it was only after discussion with a coworker she was urged to report.
The Administrator stated, [CNA1] failed to think it through and report as she should have .
This is not a failure for the facility, but more a failure for her . I can't force people to think . We can offer training, educate, and give tools but can't make them think.
During an interview on 12/23/25 at 10:02 AM, the DON stated she had submitted the follow-up investigation report to the State Agency, and this was the first one she had done on a new system.
The DON stated she understood the report was due within five days of the initial report and she thought she had submitted it on time, but when she accessed the system again on 09/08/25, she noticed the report did not get submitted.
The DON stated this may have been a glitch in the new system or user error.
Review of the facility's policy titled, Abuse Prevention and Vulnerable Adult Report Plan, dated December 2023, revealed, All persons either employed or working in any capacity . are obligated under law to make a report if they have reason to believe that abuse, exploitation, and neglect has occurred .
All alleged violation of abuse, neglect, mistreatment, or misappropriation of property must be reported immediately to the Administrator, Social Worker, Director of Nursing, and the appropriate state agencies . In accordance with state and federal law, the internal investigation must be completed in five working days.
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