Shorehaven HLTH & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Shorehaven HLTH & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Nov 14, 2022

  Based on interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R9) of 3 Residents reviewed for pressure injuries. * R9 was admitted to the facility on [DATE] with diagnoses which included a right hip fracture. The admission body check documents a 3.0 x 1.8 cm (centimeter) purple area that is not open potentially indicating the presence of a DTI (deep tissue injury). The wound assessment 8/9/22 documents a Stage 2 PI with 90% slough & 10% epithelial tissue. R9's pressure injury was not staged correctly as a Stage 2 pressure injury does not include slough. […]

• Actual harm, isolatedF689Jun 25, 2024

  Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff applied a foot pedal to a wheelchair during transport of the resident to prevent an accident for 1 of 3 sampled residents (R1) reviewed for accidents. Findings included: R1 was admitted to the facility on [DATE]. The Resident Face Sheet revealed the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the right side, vascular dementia, pain, and weakness. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2025

  Dishwasher Temperatures: The 2022 Wisconsin Food Code documents at 4-501.110 .Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74° C (165° F); (2) For a stationary rack, dual temperature machine, 66° C (150° F); (3) For a single tank, conveyor, dual temperature machine, 71° C (160°F); or (4) For a multitank, conveyor, multitemperature machine, 66° C (150° F). […]

• No harm, potential for more than minimal, patternF812Feb 22, 2024

  Based on observation, record review, and interview, the facility did not ensure food was prepared safely and temperatures taken in 5 of 5 household kitchens. This deficient practice has the potential to affect 80 of the 82 residents currently residing in the facility who receive their meals from the household kitchens. * End of service temperature checks were not being completed 4 times a month on AM and PM shift. * Temperatures were not being taken for breakfast food cooked in the individual household kitchens. Findings: The facility policy, entitled Food Preparation, revised 2/2009, states, D. A thermometer is used during food preparation to insure proper cooking temperatures for all food items. H. […]

• No harm, potential for more than minimal, isolatedF609Mar 5, 2026

  Based on interview and record review, the facility did not ensure that 2 (R1 and R3) of 2 residents with allegations of abuse were reported to the State Agency and one or more law enforcement entities. *On 2/9/26, R3 alleged Certified Nursing Assistant (CNA)-D pushed R3 against the wall and slapped R3 on the face with a wet rag. The facility did not report the allegation of abuse within 2 hours to the State Agency as required and the facility did not report the allegation of abuse to law enforcement as required. *On 1/25/26, R1 and R2 were involved in a resident-to-resident altercation. […]