Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 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.
Kitchen sanitation and food handling deficiencies were observed when the handwashing sink and convection oven had visible brown discoloration and buildup, and staff did not follow proper food service practices. The Dietary Manager wore a baseball cap without a hairnet and used gloved hands and a finger while serving dessert, while a cook used contaminated gloves to handle utensils, carts, and garlic bread during meal service instead of using tongs, contrary to facility policy.
Daily staffing information was not posted in a visible location for residents, families, and visitors to see. The staffing sheet was observed behind the nurses' station on multiple occasions, out of view, and the Administrator and DON confirmed it was being kept there after the hallway tack board broke.
The facility failed to maintain infection control practices in laundry handling and medication administration. A laundry room observation showed clean and dirty laundry used the same entrance and exit, and the DON stated this would not prevent cross-contamination. In addition, a CMA did not perform hand hygiene before returning to the med cart, touched a resident’s acetaminophen tablet with a bare hand during setup, and then administered the medication; staff interviews confirmed pills should not be handled with bare hands and hand hygiene should occur before and after a med pass.
The facility failed to serve the menu-directed 8 oz. portion of chicken and pasta alfredo to 32 of 34 residents at the noon meal. Staff used a 6 oz. scoop instead of the ordered 8 oz. scoop because the facility did not have the correct scoop size available, and the Dietary Manager, DON, and Administrator all confirmed the menu was not followed as written. The facility's Select Menu policy did not direct staff to use the proper scoop sizes.
Failure to complete a required SCSA MDS for a resident admitted to hospice care. The resident had moderate cognitive loss and diagnoses including stroke, AFib, HTN, DM, and pain, and hospice records showed a terminal diagnosis with failure to thrive and CHF. The ADON acknowledged the quarterly MDS was completed but the SCSA for hospice admission was missed, and the Regional Nurse Consultant stated the facility followed RAI guidelines without a formal MDS policy.
Failure to Notify PCP and Dietitian of Weight Changes: A resident admitted at 191 pounds had daily weights ordered with PCP notification for significant weight changes, but the record showed multiple weight increases and decreases that met the ordered thresholds without documentation of PCP, family, or dietitian notification. The chart also lacked ongoing nutritional documentation, and the DON stated the dietitian was not aware of the weight loss and the facility did not notify the PCP as ordered.
Flies were observed landing on food during meal service, including crushed pineapple and pureed peas, while four flies were present in the kitchen and a dead fly was noted on a cupboard door. The IP stated kitchen audits had not been completed, and the Administrator said the facility had bug traps but did not know when pest control last came to the facility. Facility policies directed food to be kept free of harmful organisms and substances and called for pest control methods to address seasonal pests such as flies.
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.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to clean the kitchen convection oven and the handwashing sink, and staff failed to follow food handling practices during meal service. During an initial kitchen walk-through, the white handwashing sink had a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches, and the convection oven had a brown, sticky-like discoloration on the inside and outside of the doors, throughout the inside of the oven, and on the metal racks. On a follow-up walk-through, both the sink and oven continued to show the same discoloration and buildup. During observations of food preparation and service, the Dietary Manager wore a baseball cap without a hairnet, with hair protruding below the cap. While preparing dessert, she held a cool whip container and spatula with gloved hands and used her index finger to scrape the spatula while serving the dessert. During the noon meal service, Staff D wore gloves while touching diet name cards, serving utensils, plates, and transportation carts, then used the same gloved hands to grab garlic bread and place it on residents' plates, serving approximately 32 portions. Staff D stated he did not use tongs and believed gloves alone were sufficient. The facility's policy directed staff to clean and sanitize kitchen surfaces and equipment, discard disposable gloves after each use, and use tongs or other utensils to avoid manual contact with prepared foods.
Daily Staffing Not Posted in a Visible Location
Penalty
Summary
The facility failed to post the daily staffing information every day in a visible place for all visitors and residents to see. The facility had a census of 34 residents. During an observation on 9/2/25 at 10:42 AM, the Daily Staffing was posted on a bulletin board behind the nurses' station, out of view of residents, families, and visitors. During another observation on 9/3/25 at 1:55 PM, the Daily Staffing remained in the same location behind the nurses' station and still was not visible to residents, families, and visitors. During interviews on 9/4/25, the Administrator stated the facility kept the Daily Staffing behind the nurses' station, and the DON stated it had previously been kept in the hallway in front of the nurses' station until the tack board broke, after which it was moved behind the nurses' station.
Infection Control Lapses in Laundry Flow and Medication Handling
Penalty
Summary
The facility failed to maintain an infection prevention and control program related to laundry handling. On 9/3/25, the laundry room was observed using the same entrance and exit for both clean and dirty laundry items, and the room entrance/exit measured approximately 5 feet in width. The Laundry Manager stated the same exit and entrance was used for clean and dirty laundry items. The Infection Preventionist reported she had not completed audits on laundry, and the DON stated that having clean and dirty laundry going in and out the same door would not prevent cross-contamination. The facility also failed to use proper infection control practices during medication administration. During an observation on 9/3/25, a CMA left the medication cart area without performing hand hygiene, returned with a cold tub of pudding and supplement drinks, and accessed the medication cart and laptop before administering acetaminophen to a resident. While preparing the dose, the CMA shook tablets into a lid, dropped one tablet outside the medication cup, picked it up with a bare hand, and placed it back in the cup before giving the medication. The resident’s EMAR showed the acetaminophen was signed as administered. Staff interviews confirmed that staff should not touch pills with bare hands and should perform hand hygiene before and after a medication pass, and the DON stated staff should sanitize hands or use a glove if they need to touch a resident’s medication.
Incorrect Portion Size Served at Noon Meal
Penalty
Summary
The facility failed to provide the correct portion size of 8 oz. of chicken and pasta alfredo for 32 of 34 residents during the noon meal service. The menu for Week 2 Wednesday, dated 5/14/25, directed staff to serve 8 oz. of chicken and pasta alfredo, but during meal observation on 9/3/25, Staff D used a 6 oz. scoop to serve 32 portions instead of the 8 oz. scoop listed on the menu. The Dietary Manager stated the facility provided a heaping 6 oz. scoop because there were no 8 oz. scoops available and said she told Staff D to use two 4 oz. scoops, but he did not. Staff D confirmed he used a 6 oz. scoop because the facility did not have any 8 oz. scoops. The DON and Administrator stated they expected staff to follow the menu and use the directed scoop size, and the facility's undated Select Menu policy did not include direction to use the proper scoop sizes.
Failure to Complete Required SCSA for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in status assessment for Resident #23 after the resident enrolled in hospice care. Resident #23’s record showed a BIMS score of 9 on the MDS, indicating moderate cognitive loss, and diagnoses that included stroke, atrial fibrillation, high blood pressure, diabetes mellitus, and unspecified pain. The clinical census showed the resident was admitted to hospice care, and hospice documentation reflected a start of care date with a primary diagnosis of stroke and a secondary diagnosis of failure to thrive with congestive heart failure. Hospice paperwork was signed by the resident’s legal representative, and hospice left copies of the admission paperwork for the DON and Business Office/Executive Director. The record review showed no documented SCSA MDS when the resident admitted to hospice care. The care plan later identified the resident as having a terminal diagnosis requiring hospice care and directed staff to observe for signs and symptoms of discomfort and report to the nurse, but the MDS Summary Page did not show completion of the required SCSA. During interview, the ADON stated she completed an SCSA MDS when someone admitted or discharged from hospice care or had a change in condition from baseline, and acknowledged she completed a quarterly MDS but missed the SCSA for hospice admission. The Regional Nurse Consultant stated the facility did not have an MDS policy and followed the RAI guidelines.
Failure to Notify PCP and Dietitian of Resident Weight Changes
Penalty
Summary
The facility failed to identify weight loss and failed to notify the PCP, dietitian, and/or family for Resident #3, who was admitted weighing 191 pounds and was ordered to have daily weights with PCP notification for a 3-pound change in a day or a 5-pound change in a week. The record showed weights of 197.5 pounds, 191.4 pounds, 188 pounds, 186 pounds, 185 pounds, 180.5 pounds, 179 pounds, and 180 pounds, including multiple changes that met the ordered notification thresholds, but the clinical record lacked documentation that the PCP or family was notified. The record also lacked additional documentation of nutritional status or ongoing dietitian follow-up after the initial nursing note and dietitian assessment, which both documented the resident’s admission weight of 191.4 pounds and a regular diabetic diet with unknown likes and dislikes. During interview, the DON stated the dietitian did not know about the resident’s weight loss and did not address it, and the facility did not notify the PCP of the weight increases and decreases as ordered. The administrator stated the facility did not have a weight loss policy and followed current standard of practice, and the DON stated she did not provide weekly notification to the dietitian about weight loss.
Flies observed on food during meal service
Penalty
Summary
The facility failed to keep flies off food prior to serving and did not maintain an effective pest control program. During an observation on 9/3/25 at 12:08 PM, a fly landed on two bowls of crushed pineapple and then flew over and landed on pureed peas. Four flies were present in the kitchen during the observation, and one dead fly was noted on a cupboard door from 11:55 AM to 12:55 AM. The facility reported a census of 34 residents. During an interview on 9/3/25 at 2:45 PM, the Infection Preventionist stated she had not completed audits on practices in the kitchen. During an interview on 9/4/25 at 10:37 AM, the Administrator stated the facility had bug traps but did not know when pest control last came to the facility and acknowledged that flies should not land on food during food service. Review of the facility’s undated General Food Preparation and Handling policy stated food should be prepared to conserve maximum nutritive value, develop and enhance flavor, and keep free of harmful organisms and substances. Review of the undated Pest Control Program policy directed the facility to use a variety of methods to control seasonal pests such as flies, using indoor and outdoor methods deemed appropriate by the outside pest service and state and Federal regulations.
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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Illustrative
What surveyors actually found near you
We read the 123 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 2 | 0 |
| Clarksville Skilled Nursing & Rehab Center | 7 mi | ★★★★★ | 2 | 0 |
| Rehabilitation Center Of Allison | 11.9 mi | ★★★★★ | 7 | 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 July 2026) and official state health department websites.