Shell Lake Health Care Center
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
allegations to the police and residents' physicians and representatives. The facility initiated body checks on all residents with no unexplained injuries found. Resident and staff interviews revealed no concerns with abuse or rough treatment. The facility's investigation did not substantiate that abuse occurred. CNA1 terminated her employment shortly after this incident and CNA2 was reinstated.Review of CNA2's Time Card, provided on paper by the DON, revealed CNA2 worked in the facility on 08/23/25 from 9:53 PM to 2:43 AM, on 08/24/25 from 3:18 AM to 6:47 AM and from 9:53 PM to 12:49 AM, and on 08/25/25 from 9:54 PM to 11:03 PM, at which time she was suspended pending the investigation. During an interview on 12/22/25 at 2:49 PM, the DON stated the allegations of abuse by CNA2 against Resident R1 and Resident 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 Resident R1 shouting from behind a closed door and heard a thud in the room while CNA2 was providing care. She also stated she overheard Resident 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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SHELL LAKE HEALTH CARE CENTER in SHELL LAKE, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SHELL LAKE, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SHELL LAKE HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.