Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shell Rock Senior Living during CMS and state inspections, most recent first.
The facility did not have a full-time DON and failed to provide eight consecutive hours of RN coverage on four days within a month. The previous DON resigned immediately during a state survey, leaving the facility without a full-time DON since then. The Administrator confirmed the lack of RN coverage on specific days.
A resident with moderately impaired cognition due to dementia and depression lost their hearing aid, which was not promptly replaced by the facility. The resident expressed difficulty in communication, and the responsibility was believed to be with the SW, who went on leave, leading to the oversight. The facility's grievance process policy was not followed.
A resident with severely impaired cognition and a history of hemiplegia/hemiparesis and hip fracture did not receive routine repositioning as required. Despite needing total assistance for transfers and bed mobility, staff did not assist the resident to lay down or reposition him until after lunch on most days, and the resident reported not being repositioned while in bed. A CNA confirmed the lack of repositioning, and the DON stated that all dependent residents were expected to receive routine repositioning.
A facility failed to accurately code the MDS for a resident receiving hospice services. Despite the resident starting hospice care, the MDS assessment lacked documentation of this service. The DON expected the MDS to be coded correctly using the RAI for guidance.
The facility failed to maintain sanitary conditions in its kitchen, with broken dishwashing equipment, standing debris-filled water, and flies landing on food. Observations revealed dirt, dust, and debris on kitchen surfaces, undated and open food items, and a lack of proper sanitizing agents. Staff interviews confirmed awareness of these issues and non-compliance with facility policies.
The facility failed to maintain resident dignity by serving meals on paper plates with Styrofoam glasses and plastic silverware due to a broken garbage disposal and previously malfunctioning dishwasher. Residents and staff expressed dissatisfaction with the disposable dining ware, noting it detracted from the dining experience. The issue persisted for weeks, with residents feeling frustrated over the delay in resolving the problem.
A resident with a history of stroke and dementia fell and sustained a femoral fracture and scalp laceration during a mechanical lift transfer when a CNA attempted the transfer alone, contrary to the care plan requiring two staff members.
Deficiency in RN Coverage and DON Availability
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing (DON) and did not provide eight consecutive hours of Registered Nurse (RN) coverage for four days within a 30-day period. The nursing schedules from August 12, 2024, to September 12, 2024, showed a lack of RN coverage on August 16, 19, 28, and September 2, 2024. The facility had a census of 34 residents during this time. The DON, who was also a Regional Clinical Quality Specialist, reported that the previous DON resigned immediately upon learning of the state survey, leaving the facility without a full-time DON since August 12, 2024. The Administrator confirmed the absence of RN coverage on the specified days and the prior DON's last day of work was August 12, 2024.
Failure to Replace Missing Hearing Aid for Resident
Penalty
Summary
The facility failed to address the issue of a missing hearing aid for a resident, identified as Resident #25, who had moderately impaired cognition due to dementia and depression. The resident's Minimum Data Set (MDS) assessment indicated the use of a hearing aid, which was reported missing. Despite the resident expressing difficulty in communication due to the loss of the hearing aid, the facility did not take prompt action to find or replace it. The Director of Nursing (DON) acknowledged that the responsibility was believed to be with the Social Worker (SW), who went on leave, leading to the oversight. The facility's grievance process policy, which mandates prompt resolution of grievances, was not adhered to in this case.
Failure to Provide Routine Repositioning for a Resident
Penalty
Summary
The facility failed to provide routine repositioning for Resident #19, who had severely impaired cognition with a BIMS score of 8 and required total assistance for transfers and bed mobility. The resident had a history of hemiplegia/hemiparesis, a hip fracture, and was at high risk for falls. Despite the care plan indicating the need for assistance from two staff members to reposition and turn the resident in bed, observations and interviews revealed that staff did not assist the resident to lay down or reposition him until after lunch on most days. Additionally, the resident reported not being repositioned while in bed, and a CNA confirmed that staff never repositioned him when in bed. The Director of Nursing stated that all dependent residents were expected to receive routine repositioning.
MDS Coding Error for Hospice Services
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was receiving hospice services. The resident began hospice care on September 28, 2023, but the MDS assessment did not document this service. The Director of Nursing stated that the facility was expected to code the MDS correctly if a resident received hospice services, using the Resident Assessment Instrument (RAI) for guidance.
Unsanitary Food Service Conditions in Facility Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, it was observed that the facility lacked working equipment necessary for cleaning dishes, such as a dishwasher and garbage disposal. The dishwasher was not releasing the required chemicals for cleaning, and the sink used for garbage disposal was filled with standing debris-filled water. Additionally, the kitchen was found to have multiple items covered in dirt, dust, and debris, along with undated and open food items. Flies were observed landing on food, and there were spiderwebs and mold present in the kitchen. The surveyor documented numerous specific instances of unsanitary conditions during the kitchen tour. These included a fly on a cake, dead flies on countertops, and a buildup of grease, dust, and dirt on various kitchen surfaces. Food, dirt, and debris were found on walls, silverware, and kitchen equipment. The refrigerator contained undated and opened food items, and there was a buildup of a brown substance inside. The freezer had spilled ice cream dripping onto other food items, and the dishwasher area was filled with tan-colored water and food particles. Interviews with staff members revealed that they were aware of the unsanitary conditions and the broken equipment. Staff members confirmed the presence of flies and acknowledged that the kitchen was dirty. They also admitted to not testing sanitizing agents and not labeling or dating food items properly. The Dietary Manager confirmed that the sanitizing agents were not at the required levels, and the dishwasher was not functioning correctly. The facility's policies and procedures for food storage and cleaning were not being followed, contributing to the unsanitary conditions.
Removal Plan
- The facility disposed of the prepped evening meal and procured the evening meal from an outside source.
- The facility switched to paper products for all dinnerware until the repair of the dishwasher.
- The facility contacted their food and equipment provider to schedule the repair of the chemical dispensers on the dishwasher and the 3-compartment sink. The facility put these out of service until the completion of the appropriate repairs.
- The facility disposed of all undated/unlabeled food items.
- The facility initialized cleaning of the food debris in the refrigerators, counters, and other areas. The facility will have the cleaning of the areas completed prior to beginning any food prep in those areas.
- The facility added additional fly traps in the kitchen area.
- The facility contacted the regional maintenance person regarding the garbage disposal in the dish washing area.
- The facility-initiated staff education on the following: Food Storage, Employee Sanitary Practices, Dry Storage Areas, Cleaning and Sanitation of Food Service Areas, Dish Machine, Pest Control.
- The facility planned to procure food from alternative sources until they could address all areas of concern appropriately and the necessary utilities worked.
Failure to Maintain Resident Dignity in Meal Service
Penalty
Summary
The facility failed to maintain and promote the dignity of residents by serving meals on paper plates with Styrofoam glasses and plastic silverware for an extended period. This issue arose due to a broken garbage disposal and a previously malfunctioning dishwasher, which led to the use of disposable dining ware. The Dietary Manager confirmed that the garbage disposal had been broken for two weeks, with parts on back order, and that meals were served on paper products because of these equipment failures. Despite the dishwasher being repaired, the continued use of disposable items was due to the garbage disposal issue. Residents expressed dissatisfaction with the use of paper plates and plastic silverware, feeling that it detracted from their dining experience. One resident reported that the problem had persisted for a month and expressed frustration over the facility's delay in resolving the issue, especially given the premium price paid for their stay. Staff interviews corroborated the residents' complaints, noting that the residents disliked the disposable dining ware, particularly the sporks used as silverware. The facility's actions during the surveyor's presence, where meals were served on ceramic plates, further highlighted the inconsistency in maintaining residents' dignity.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to ensure staff provided a safe transfer with a mechanical lift for a resident who required transfer assistance. The resident, who had a history of stroke, dementia, and hemiplegia, required substantial to maximal assistance with transfers and bed mobility. On the day of the incident, two CNAs were providing perineal care to the resident when one CNA left the room to attend to another resident's call light. The remaining CNA attempted to transfer the resident alone using a full-body mechanical lift, during which the resident began to cough vigorously, causing the sling to come undone from the lift. The resident fell to the floor, striking their head and sustaining a left femoral fracture and a scalp laceration. The resident's care plan indicated that two staff members were required for all transfers using a full-body mechanical lift. However, this protocol was not followed at the time of the incident. The CNA who continued the transfer alone confirmed that the facility policy required two staff members for such transfers and that she had been educated on this requirement. The mechanical lift and sling were inspected after the incident and found to be in good working condition, although a missing spring in the lift's clip was identified and replaced. Interviews with staff and the Director of Nursing confirmed that the facility's policy mandated the use of two staff members for mechanical lift transfers to ensure resident safety. The investigation also revealed that the facility had been using incompatible slings with the mechanical lifts, which were subsequently discarded and replaced with compatible ones. The incident highlighted a failure to adhere to established safety protocols, resulting in significant injury to the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shell Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodland Terrace | 4.2 mi | — | 0 | 0 |
| Clarksville Skilled Nursing & Rehab Center | 7 mi | — | 2 | 0 |
| Rehabilitation Center Of Allison | 11.9 mi | — | 0 | 0 |
| Denver Sunset Home | 12.4 mi | — | 2 | 0 |
| Cedar Falls Health Care Center | 13.8 mi | — | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.