Edgewater Haven Nursing Home

In the surveyor’s words

From the most serious findings on record at Edgewater Haven Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Jun 26, 2024

  Based on staff interview and record review, the facility did not have qualified staff onsite to supervise kitchen operations. This had the potential to affect all 47 residents residing in the facility. Dietary Manager (DM)-D did not have a qualified certification to manage the kitchen. DM-D stated DM-D had access to a contracted Registered Dietician (RD) who worked remotely and was not onsite for supervision. Findings include: On 6/24/24 at 11:48 AM, Surveyor interviewed DM-D who stated DM-D worked as the Dietary Manager for a little over one year and was in the process of taking a ServeSafe course and another unknown course that was assigned by the facility's food service vendor. DM-D confirmed DM-D was not certified as a Dietary Manger. […]

• No harm, potential for more than minimal, widespreadF812Jun 26, 2024

  Based on observation, staff interview, and record review, the facility did not ensure food was stored in accordance with professional standards for food service safety. This practice had the potential to affect all 47 residents residing in the facility. Boxes containing food intended for resident use were stored on the floor in the freezer. Raw meats were stored over pre-cooked food in a reach-in cooler. Findings include: The Wisconsin Food Code documents at Preventing Contamination from the Premises 3-305.11 Food Storage: (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 centimeters (6 inches) above… […]

• No harm, potential for more than minimal, widespreadF812May 19, 2022

  Based on observation and interview, the facility did not ensure staff stored, prepared, and distributed food according to professional standards. This had the potential to affect all 42 residents. -Food in fridge was not covered and dated -Not maintaining temp logs for cooler/freezer/dishwashing machine -Staff are not practicing appropriate glove use This is evidenced by: On 05/16/22 at 9:25 AM during initial tour with Dietary Supervisor (DS) E, Surveyor observed coolers, cooler temps, and freezer temps were all within normal range. When Surveyor asked to see the temperature logs for the coolers and freezers May 1st through the 8th, no temps were documented on the log. Surveyor asked DS E if that meant it was not done. […]

• No harm, potential for more than minimal, widespreadF880May 19, 2022

  Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection, such as COVID-19, which had the potential to affect all 42 residents (R) of the facility. Throughout the survey, observations were made in which: - Staff did not sanitize goggles when moving from a positive Covid-19 resident to a negative resident room or change their contaminated N95 masks prior to caring for a resident that is negative for Covid-19; - R2 and R36 were in precautions for positive Covid-19. […]

• No harm, potential for more than minimal, patternF761Aug 13, 2025

  Based on observation, staff interview, and record review, the facility did not ensure 3 treatment carts were locked when unattended and did not ensure 1 of 2 medication carts and 1 medication storage room were free of expired medications and supplies. This practice had the potential to affect more than 4 of the 46 residents residing in the facility.Treatment carts on the 300 and 500 wings were left unlocked and unattended. The 300 north medication cart contained expired medications and supplies. The 300 wing medication room contained expired medication, supplements, food items, and medical supplies.Findings include: The facility's Pharmacy Policy and Procedure Manual, Storage and Maintenance of Medication policy, dated April 15th, indicates: 1. […]