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 Lake Health Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were involved in an incident where a CNA failed to immediately report suspected physical abuse by another CNA, resulting in a delay in removing the alleged perpetrator from duty. The facility also did not submit the required five-day follow-up investigation report to the State Agency on time, contrary to policy requirements.
A resident with serious health conditions did not receive appropriate respiratory care as per physician orders. The oxygen was set at 2 liters per minute instead of the ordered 3 liters, and there was no record of when the nasal cannula tubing was changed or the oxygen concentrator filter was cleaned. The LPN was unaware of the correct oxygen flow rate, and the DON confirmed the incorrect setting and uncleaned filter.
A resident with severe cognitive impairment and multiple medical conditions received care that did not adhere to infection control protocols. CNAs failed to sanitize hands after glove removal and improperly disposed of soiled water, indicating a lack of awareness of proper sanitation practices. The DON confirmed the expected procedures, highlighting a deficiency in staff training and adherence to infection control standards.
A resident with cognitive impairment and mobility issues was improperly transferred by a CNA alone, resulting in a fall and a swollen hip. The incident was not reported to the administration, and there was no documentation of the fall, contrary to facility policy requiring immediate reporting and assessment by the charge nurse.
Two residents in an LTC facility did not receive timely assistance with toileting and personal hygiene, leading to prolonged periods in soiled briefs. One resident, with multiple medical conditions, was not assisted for over four hours, while another resident's call light was ignored for 79 minutes. Staffing issues and inadequate adherence to care plans and facility policies contributed to these deficiencies.
Three residents at high risk for pressure injuries did not receive necessary care to prevent or manage pressure ulcers. One resident was not repositioned for over four hours, resulting in redness and wrinkling of the skin. Another resident with a scapula pressure ulcer was left in a position that increased pressure on the affected area. A third resident did not have required Podus boots applied, leading to the reopening of a heel wound.
Two residents at risk for falls did not receive adequate supervision and assistance devices, leading to deficiencies in their care. One resident, with significant cognitive impairment, was improperly transferred by a single CNA, resulting in a fall. Another resident, requiring a knee immobilizer for stability, was transferred without it by a CNA. These incidents highlight a lack of adherence to care plans and proper reporting procedures.
The facility was found to have insufficient nursing staff, resulting in delayed care for residents. One resident with multiple medical conditions waited 79 minutes for assistance, while another with a pressure injury was not repositioned for over four hours. A third resident with dementia also experienced delays in receiving help. These incidents highlight the facility's failure to provide adequate staffing to meet resident needs.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that allegations of physical abuse involving two residents were reported immediately and that the required five-day follow-up investigation report was submitted to the State Agency in a timely manner. One resident, who had dementia and severely impaired cognition, and another resident, who had a history of subarachnoid hemorrhage and moderately impaired cognition, were both identified as vulnerable adults in their care plans. The care plans specified that any situation identified as abuse or potential abuse would be reported per facility protocol. On the evening in question, a CNA heard a thud and a resident shouting from behind a closed door while another CNA was providing care, and also overheard a second resident telling the same CNA to stop being rough. The CNA did not report these concerns until her next shift, two days later, stating that there was no one available to report to at the end of her shift and that she was unsure if what she witnessed constituted potential abuse. The delay in reporting meant that the alleged perpetrator continued to work additional shifts before being suspended pending investigation. The facility's initial report to the State Agency was made after the delayed internal report, and the follow-up investigation report was not submitted within the required five-day period. The DON later discovered that the report had not been submitted due to a possible system error or user mistake. The facility's policy required immediate reporting of all alleged violations and completion of the internal investigation within five working days, which was not followed in this instance.
Deficiency in Respiratory Care for Resident
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for a resident with multiple serious health conditions, including COPD, congestive heart failure, stroke, and stage 5 kidney disease, who is also receiving hospice services. The resident was observed using oxygen via a nasal cannula continuously, but the oxygen was set at 2 liters per minute instead of the physician-ordered 3 liters per minute. Additionally, the facility did not maintain proper records of when the nasal cannula tubing was changed or when the oxygen concentrator filter was cleaned, as required by the physician's orders. During the survey, the LPN was unaware of the correct oxygen flow rate and could not confirm when the tubing and filters were last serviced. The Director of Nursing confirmed the incorrect oxygen flow rate and the presence of dust on the oxygen concentrator filter, indicating it had not been cleaned as required. The facility also failed to provide the manufacturer instructions or policy and procedure for oxygen/respiratory care when requested by the surveyor.
Infection Control Deficiency During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the care of a resident with severe cognitive impairment and multiple medical conditions, including dementia, cerebral palsy, stroke, type 2 diabetes, epilepsy, and left-sided paralysis. The resident, who requires assistance for mobility and uses a Broda chair and Hoyer lift, was observed receiving pericare from two CNAs. During this process, CNA D did not sanitize her hands after removing gloves following pericare and before handling the resident's dentures, which is a breach of infection control protocols. Additionally, CNA C improperly disposed of soiled water from the wash basin in a sink where the resident's denture cup was present, indicating a lack of awareness of proper sanitation practices. When questioned by the surveyor, CNA C admitted to not knowing the correct procedure. The Director of Nursing (DON) confirmed that hand hygiene should be performed after glove removal and that wash basins should be emptied in the toilet, highlighting a deficiency in staff training and adherence to infection control standards.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to implement its written policies and procedures when an incident of caregiver neglect was not reported to the administrator immediately. A resident with significant cognitive impairment and requiring extensive assistance for mobility and transfers was improperly transferred by a CNA alone, contrary to the care plan that required assistance from two people or a mechanical Hoyer lift. During the transfer, the CNA tripped over the resident's non-functional leg, resulting in the resident falling to the floor and suffering a swollen hip. Despite the incident, it was not reported to the appropriate personnel, and there was no documentation of the fall. Interviews revealed that the CNA involved in the incident reported the fall to an RN, who assessed the resident but did not report the incident to the administration. The DON was unaware of the fall and only knew of the CNA's foot injury. The facility's policy requires staff to report falls immediately to the charge nurse, who should assess the resident, provide interventions, and investigate the root cause to determine if caregiver neglect occurred. However, this process was not followed, and the CNA's misconduct was not reported to the administration.
Failure to Provide Timely Toileting and Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for two residents, R9 and R4, to maintain good grooming, toileting, and personal hygiene. R9, who has medical diagnoses including diabetes mellitus type 2, a recent cerebral infarction, unspecified depression, and dementia, requires partial to moderate assistance for daily activities and is dependent on staff for toileting hygiene. Despite the care plan indicating scheduled toileting every two hours, R9 was not assisted with toileting for over four hours, resulting in R9 sitting in a soiled brief, which caused redness and wrinkling of the skin. R4, admitted with diagnoses including heart failure, cellulitis, chronic kidney disease, and a stage 1 pressure injury, also experienced a lack of timely assistance. R4's care plan included a toileting schedule, but during a 79-minute observation, R4's call light was ignored multiple times by various staff members, including the DON and CNAs. R4 repeatedly requested assistance to use the bathroom but was not helped until much later, resulting in incontinence care being delayed. The deficiencies were attributed to staffing issues, with new and inexperienced CNAs being assigned to heavy halls without adequate support. The DON and LPNs acknowledged the responsibility to ensure care according to written care plans but cited challenges in staffing and communication as contributing factors to the failure in providing timely care. The facility's policy on responding to call lights was not adhered to, further exacerbating the situation.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents at high risk for pressure injuries. Resident R9, who has multiple medical conditions including diabetes and dementia, was observed for over four hours without being repositioned, despite being at high risk for pressure injuries due to immobility and incontinence. R9 was found with a red and wrinkled buttocks, indicating prolonged pressure and exposure to urine and feces. The care plan for R9 included repositioning every two hours and the use of pressure relief boots, but these interventions were not consistently implemented. Resident R5, who has scoliosis and cerebral palsy, was also not repositioned adequately. Despite having a pressure ulcer on the right scapula, R5 was observed in a supine position with pressure on the affected area for over four hours. The care plan required repositioning every two hours, but this was not followed, and the resident was left in a position that exacerbated the existing pressure injury. Resident R27, with a history of infection and diabetes, was observed without the required Podus boots for heel protection. The boots were supposed to be worn at all times to prevent pressure injuries, but they were found across the room, and the resident's heels were lying directly on the bed. Despite the care plan and physician orders, the staff failed to ensure the boots were applied, leading to the reopening of a previously healed heel wound.
Inadequate Supervision and Assistance for Residents at Risk of Falls
Penalty
Summary
Two residents at risk for falls did not receive adequate supervision and assistance devices, leading to deficiencies in their care. The first resident, R20, who has significant cognitive impairment and requires the assistance of two staff members for transfers, was improperly transferred by a single CNA, resulting in a fall. Despite the care plan specifying the use of a Hoyer lift and assistance from two staff members, CNA M attempted a stand pivot transfer alone, causing both the CNA and R20 to fall. Although the incident was reported to RN L, there was no documentation of the fall or subsequent assessments in R20's electronic health record, and the Director of Nursing was unaware of the incident. The second resident, R27, who also has significant cognitive impairment and requires a knee immobilizer for stability during transfers, was observed being transferred without the immobilizer by CNA G. R27's care plan clearly states the need for the immobilizer during transfers to prevent injury, yet CNA G failed to apply it, citing the resident's recent return from the hospital as the reason. Interviews with the LPN and PTA confirmed the necessity of the immobilizer for R27's safety, but the deficiency was observed by the surveyor. These incidents highlight a lack of adherence to care plans and proper reporting procedures, resulting in inadequate supervision and assistance for residents at risk of falls. The failure to follow established protocols and document incidents properly contributed to the deficiencies observed by the surveyors.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents, as evidenced by observations and interviews conducted by surveyors. The staffing plan indicated a certain number of licensed nurses and nurse aides, but observations showed that the facility was not adequately staffed to meet the needs of residents, particularly those dependent on staff for activities of daily living and mechanical lift transfers. Staff interviews confirmed that the facility required two trained staff for mechanical lift transfers, but the staffing levels were insufficient to meet these needs. One resident, identified as R4, was observed to have their call light on for 79 minutes without receiving assistance, despite multiple staff members walking past the room. R4, who has several medical conditions including heart failure and chronic kidney disease, required substantial assistance with toileting and transfers. During the observation period, R4 was not assisted in a timely manner, leading to a delay in receiving necessary care. Interviews with staff revealed that the workload and staffing levels were not sufficient to meet the needs of residents like R4. Another resident, R9, who has a pressure-related deep tissue injury and is at high risk for additional pressure injuries, was not offered toileting or repositioning for over four hours. This lack of care resulted in redness and wrinkling of the skin due to prolonged pressure and incontinence. Similarly, R2, who has Alzheimer's disease and dementia, was observed with their call light on for over an hour without receiving assistance. Despite multiple staff members walking past, R2 did not receive the necessary help to use the bathroom and get into bed. These incidents highlight the facility's failure to provide adequate staffing to ensure timely and appropriate care for residents.
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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 Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dove Healthcare - Spooner | 10.9 mi | — | 1 | 0 |
| Care And Rehab - Cumberland | 16.3 mi | — | 14 | 0 |
| Frederic Nursing And Rehab Community | 19.2 mi | — | 0 | 0 |
| United Pioneer Home | 22.4 mi | — | 7 | 0 |
| Dove Healthcare - Rice Lake | 24.1 mi | — | 1 | 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.