**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not provide the appropriate treatment and services related to bowel and bladder continence for 2 residents (R) (R23 and R41) of 16 sampled residents.R23 had an indwelling catheter and was continent of bowel which was noted on R23's plan of care. During an observation of care on 8/13/25, staff put an incontinence product on R23. R41's care plan did not reflect a need or desire to wear two incontinence products at once. During an observation of care on 8/12/25, staff applied two incontinence products to R41. Findings include:The facility's Urinary policy, dated 9/7/22, indicates: .Nursing staff will develop an individualized plan of care for all residents .1.From 8/11/25 to 8/13/25, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had diagnoses including bacterial pneumonia, severe sepsis, benign prostatic hyperplasia (BPH), chronic kidney disease stage 3, pressure ulcer of sacral region stage 2, and retention of urine. R23's Minimum Data Set (MDS) assessment, dated 7/17/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R23 had intact cognition. The MDS assessment also indicated R23 had an indwelling catheter and was always continent of bowel. A care plan indicated R23 had an indwelling catheter and was continent of bowel. The care plan did not indicate the need for R23 to wear an incontinence product.On 8/13/25 at 8:29 AM, Surveyor observed catheter care for R23. Certified Nursing Assistant (CNA)-E was in the shower room with R23 who was clad in a brief and a gown. On 8/13/25 at 1:52 PM, Surveyor interviewed CNA-K who indicated R23 is not incontinent of bowel and communicates to staff when R23 needs to have a bowel movement. On 8/13/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated if a resident needs an incontinence product, it should be noted on the resident's care plan. DON-B directed Surveyor to speak with Registered Nurse (RN)-L who maintained residents' care plans. On 8/13/25 at 2:14 PM, Surveyor interviewed RN-L who confirmed bowel assessments and nurse charting indicated R23 was not incontinent of bowel and did not need to wear an incontinence product. RN-L also confirmed the use of an incontinence product was not listed on R23's care plan or status sheet. On 8/13/25 at 3:00 PM, Surveyor interviewed R23 who indicated R23 did not request to wear a brief and was not sure why staff put a brief on R23. 2. From 8/11/25 to 8/13/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including fracture of the left femur, anxiety disorder, osteoarthritis, and mixed incontinence. R41's MDS assessment, dated 6/12/25, had a BIMS score of 14 out of 15 which indicated R41 had intact cognition. The MDS assessment also indicated R41 was frequently incontinent of urine but always continent of bowel.A care plan indicated R41 was incontinent of bladder and wore adult briefs. On 8/12/25 at 6:05 AM, Surveyor observed peri-care for R41. CNA-E removed R41's brief and assisted R41 to the toilet. CNA-E then placed a pad liner in a pull-up product for R41. When Surveyor asked if R41 wore two incontinence products, CNA-E indicated R41 wore two incontinence products most of the time because R41 urinated heavily. On 8/13/25 at 1:48 PM, Surveyor interviewed R41 who indicated a nurse decided R41 needed to wear two incontinence products. R41 indicated R41 did not request to wear two incontinence products related to heavy urination. On 8/13/25 at 1:54 PM, Surveyor interviewed DON-B who indicated staff should not apply double incontinence products unless requested by the resident or the resident's representative. DON-B indicated the use of double incontinence products should be noted on the resident's care plan and status sheet. DON-B directed Surveyor to speak with RN-L who maintained residents' care plans. On 8/13/25 at 2:14 PM, Surveyor interviewed RN-L who reviewed R41's medical record and indicated it did not appear that R41 or R41's representative requested double incontinence products for R41. RN-L indicated CNAs are instructed not to apply double incontinence products unless requested by the resident or the resident's representative or instructed to do so by DON-B or the nursing supervisor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R7) of 1 sampled resident received dialysis care and services in accordance with the facility's policy.Findings include:The facility's Dialysis policy, dated 10/29/20, indicates under care protocols for arteriovenous (AV) fistula or graft access point: .7. There must be communication between the facility and the dialysis center. The appropriate communication should be sent with the resident in a binder to each dialysis session. The dialysis staff should return a report when the resident returns to the facility which includes basic information including pre- and post- weights, vital signs, and any other pertinent information obtained during the procedure.The facility's Nursing Home Dialysis Transfer Agreement, dated August 2018, indicates: .The Center will develop a written protocol governing specific responsibilities, policies, and procedures to use in rendering dialysis services to designated residents at the Center, including but not limited to the development and implementation of a designated resident's care plan relative to the provision of dialysis services.From 8/11/25 to 8/13/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, anemia, chronic kidney disease stage 5, and dependence on renal dialysis. R7 was R7's own decision maker. R7's medical record indicated R7 received dialysis and had an AV fistula.A care plan, initiated 9/18/14, indicated R7 required dialysis related to end stage renal disease (ESRD). The care plan did not include R7's dialysis days or times or indicate how R7 was transported to and from the dialysis center.R7 had an order for daily weights. Surveyor reviewed R7's weights for 7/8/25 to 8/12/25 and noted R7's medical record did not contain documented weights or indicate weights were communicated to the dialysis center on 7/19/25, 7/24/25, 7/26/25, and 7/29/25.On 8/12/25 at 1:56 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who indicated nurses enter R7's dialysis dates and times on a calendar. CNA-K indicated R7 takes a dialysis binder with R7 to the dialysis center.On 8/12/25 at 2:08 PM, Surveyor interviewed R7 who verified R7 receives dialysis. R7 indicated staff need to provide R7's weight, vital signs, medication, and breakfast before R7 leaves for dialysis appointments. R7 indicated R7's weight is also obtained at the dialysis center before and after dialysis. R7 indicated the dialysis center is supposed to document on a continuity of care document in the front of the binder that the facility sends with R7 and that R7 drops off at the nurses' station upon return.On 8/13/25 at 12:43 PM, Surveyor interviewed Registered Nurse (RN)-F who confirmed a continuity of care document is sent with R7 to each dialysis session. RN-F indicated the document contains R7's input and output, medications administered, contact information, vital signs, and weight. RN-F confirmed R7 had an order for daily weights and indicated the dialysis center did not consistently report back to the facility for the times R7 was there. RN-F indicated the dialysis center should provide the facility with R7's pre- and post-weights and changes that occur. RN-F indicated the dialysis center puts new orders in the front pocket of the binder for staff tor review.On 8/13/25, Surveyor reviewed communication sheets from the dialysis center and noted the facility received 6 communication sheets from the dialysis center from 1/2025 to 8/13/25.On 8/13/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the dialysis center should communicate R7's pre- and post-weights, vital signs, and other pertinent information following each dialysis session. DON-B also verified R7's care plan should include R7's dialysis days and times and indicate that R7 receives dialysis services.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R3 and R23) of 16 sampled residents. Staff did not follow enhanced barrier precautions (EBP) during the provision of care for R3.Staff did not follow EBP or ensure a catheter bag and tubing were not in contact with the floor during the provision of care for R23.Findings include:The facility's Enhanced Barrier Precautions (EBP) policy, dated 6/22/24, indicates: EBP expand the use of personal protective equipment (PPE) and refer to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing .Residents colonized with a targeted MDRO will be placed on EBP and staff will wear a gown and gloves for high-contact activities. Residents with indwelling medical devices or chronic wounds regardless of having an MDRO will be placed on EBP. Examples of high-contact resident cares activities requiring gown and glove use for EBP include: Dressing; Bathing; Transferring; Providing hygiene; Changing linens; and Device care or use: Urinary catheter.The facility's Daily Care Required for a Resident with Indwelling Catheter policy, dated 2/11/21, indicates: .8. Observe bag. Bag should not touch floor .1.On 8/11/25 at 10:19 AM, Surveyor observed Certified Nursing Assistant (CNA)-D assist R3 into an electric wheelchair. Surveyor observed a sign on R3's door that indicated R3 was on EBP. Surveyor noted CNA-D did not wear a gown during the transfer. Surveyor also observed CNA-D hold R3's catheter bag, help put R3's feet on the wheelchair pedals, and hang R3's catheter bag from the wheelchair.2. On 8/13/25 at 7:26 AM, Surveyor noted a sign on R23's door that indicated R23 was on EBP. When Surveyor entered R23's room to observe care, Surveyor noted CNA-E transferred R23 to a wheelchair while wearing gloves but not a gown. When asked if R23 was on EBP and if PPE was needed for cares, CNA-E indicated R23 was on EBP and CNA-E would get a gown when R23 was in the shower room. CNA-E put R23's catheter bag in a cover, removed linens from R23's bed, and removed a Chux pad from R23's chair. CNA-E then removed gloves, cleansed hands, and covered R23 with a blanket that was on R23's recliner. Surveyor noted R23's catheter tubing was on the floor. When Surveyor indicated the catheter tubing was on the floor, CNA-E clamped the tubing to R23's wheelchair with ungloved hands.On 8/13/25 at 8:29 AM, Surveyor entered the shower room to observe catheter care for R23. CNA-E donned a gown prior to entering the shower room and assisted R23 to the grab bars so R23 could stand. CNA-E put R23's catheter bag on the shower room floor and replaced R23's wheelchair with a shower chair. CNA-E then picked up and gave the catheter bag to R23 to hold while R23 got in the bathtub.On 813/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should wear a gown and gloves during high-contact cares for residents on EBP, including transfers, catheter care, and changing/handling linens. DON-B also indicated catheter bags and tubing should not be on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. All drugs and biologicals are to be stored in a locked designated cabinet .All medications, except those requiring refrigeration, shall be kept in locked medication carts and cabinets. 2. Outdated refrigerator items must be removed from the refrigerator .8. Medication must be checked regularly for expiration dates and deterioration. Expired items are to be removed from use and returned to the pharmacy or disposed of according to facility procedures. 9. Medications no longer in use are returned .or destroyed or credited where applicable in accordance with state and federal regulations.On 8/12/25 at 5:25 AM, Surveyor entered the 500 wing and an observed an unlocked treatment cart in the hallway. The treatment cart contained medicated creams, ointments, and powders. Surveyor interviewed Registered Nurse (RN)-G who indicated treatment carts should be locked when unattended.On 8/12/25 at 5:30 AM, Surveyor entered the 300 wing and noted the 300 south and 300 north treatment carts were unlocked and unattended. The treatment carts contained medicated creams, ointments, and powders. At 5:31 AM, Surveyor interviewed AM shift RN-H who indicated treatment medication carts should be locked when unattended and directed Surveyor to night shift RN-I.On 8/12/25 at 5:33 AM, Surveyor interviewed RN-I who confirmed treatment carts should be locked when unattended.On 8/12/25 at 11:18 AM, Surveyor observed the 300 north medication cart and noted the following expired items:~ 3 povidone-iodine swab sticks that expired 3/2025~ 21 povidone-iodine prep pads that expired 3/2025~ 32 [NAME] oil emulsion dressings that expired 5/2025~ Gold Bond medicated powder for R33 that expired 6/2023~ Triamcinolone 0.1% cream for R17 that expired on 5/4/25~ Nystatin powder for R18 that expired on 7/31/25Surveyor also observed the 300 wing medication room and noted the following expired items:~ 3 Premier Protein chocolate shakes that expired on 6/30/24~ An Anoro Ellipta inhaler for R16 that expired 12/2024~ A bottle of fluticasone propionate nasal spray for R16 that expired 5/2025~ 14 AutoShield insulin pen needles for R16 that expired 6/2025~ 9 Unifine pen tips plus insulin pen needles for R16 that expired on 12/28/23~ Glucose central solution EvenCare G3 that expired on 1/11/24~ 1 bottle of Aspirin 325 milligrams that expired 4/2025~ 1 bottle of Lantus insulin for R7 that expired on 7/11/25~ 1 container of Thick & Easy orange juice that expired on 11/30/24~ 1 vanilla Novasource renal dialysis shake that expired on 7/25/25~ 1 bottle of Hershey's chocolate syrup that expired 4/2025~ 10 boxes of InteliSwab COVID 19 rapid tests that expired on 10/31/24~ 8 blue top blood vials that expired on 7/31/25~ 13 blunt fill needles with filters that expired on 3/31/25~ 16 dark green top blood vials that expired on 5/2/25On 8/12/25 at 12:32 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-J who verified the expiration dates of the above items and confirmed the items were expired.On 8/13/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed expired items should not be in medication carts or medication storage rooms.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, and appeal rights. R22 was transferred to the hospital on 4/25/24 and was not provided a written transfer notice. Findings include: On 4/25/24, Surveyor reviewed R22's medical record. Documentation indicated R22 was transferred to the emergency room (ER) on 4/25/24 and returned to the facility the same day with a diagnosis of constipation. R22's medical record did not include documentation that a written transfer notice was provided to R22. On 6/26/24 at 12:57 PM, Surveyor interviewed Director of Nursing (DON)-B and Social Worker (SW)-F who verified the facility did not provide a written transfer notice for R22 on 4/25/24. DON-B stated the facility did not have a transfer/discharge notice form or a policy for transfer notices but needed to include a form and policy in their future process. On 6/26/24 at 1:20 PM, Surveyor received a document titled Appeal Process for Involuntary Discharge from SW-F who stated residents received the document on admission but the document was not provided for transfers/discharges and was not signed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 resident (R) (R17) of 1 resident reviewed for smoking. R17 was a known smoker. The facility did not complete a smoking assessment for R17. Findings include: The facility's Smoking-Free Policy, dated 1/14/20. indicates: Residents will agree not to smoke or use electronic cigarettes .at Edgewater Haven upon admission in the facility, or on the grounds .Residents who wish to continue to smoke must do so off the grounds by signing out with help of family or friends . On 6/24/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including fracture to left pubis, post traumatic stress disorder (PTSD), acute myocardial infraction (heart attack), and Takotsubo syndrome (sudden temporary weakening of the muscular portion of the heart). R17's Minimum Data Set (MDS) assessment, dated 2/16/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 had intact cognition. R17 did not have an activated Power of Attorney (POA) and made R17's own healthcare decisions. During the entrance conference on 6/24/24 at 9:49 AM, Nursing Home Administrator (NHA)-A stated the facility was smoke-free and there were no residents in the building who smoked. On 6/24/24 at 11:13 AM, Surveyor interviewed R17 who stated R17 could smoke when R17 wanted to smoke. R17 stated R17 had a flag for R17's wheelchair and had to go to the curb to smoke. On 6/25/24, Surveyor reviewed R17's care plan which stated, Resident will refrain from using tobacco products, e-cigarettes and vaping devices while at Edgewater Haven. On 6/25/24 at 2:40 PM, Surveyor interviewed Registered Nurse (RN)-C who confirmed R17 smoked independently. RN-C stated R17 needed to sign R17's self out at the nurses' station and staff provided R17's cigarettes and lighter. RN-C stated R17 smoked at the curb and returned the cigarettes and lighter to staff when R17 returned to the building. On 6/25/24 at 2:52 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R17 smoked and stated R17 did not need a smoking assessment because R17 did not smoke on facility grounds. DON-B verified R17's lighter was kept at the nurses' station, but was unsure if R17's cigarettes were kept at the nurses' station. When Surveyor asked about monitoring for R17, DON-B stated R17 went to therapy to ensure R17 was safe to leave the grounds. On 6/25/24 at 2:55 PM, Surveyor interviewed NHA-A who stated R17 was R17's own person and did what R17 wanted. NHA-A confirmed R17 used an orange flag provided by therapy when R17 left the facility and stated R17 was assessed by therapy as safe to leave the building. NHA-A stated staff can smoke on facility property, however, residents are not permitted to smoke on facility property. NHA-A stated R17 signed a non-smoking consent prior to admission and said R17 is the only resident who smokes. On 6/26/24, Surveyor reviewed a discharge status and recommendation therapy note for R17, dated 3/6/24. The therapy note did not include information related to R17's ability to safely smoke or leave facility property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure monitoring for adverse reactions of high risk medications for 2 residents (R) (R9 and R22) of 5 residents reviewed for unnecessary medications. R9 was prescribed bumetanide (a diuretic medication) for congestive heart failure (CHF) and chronic kidney disease (CKD). The facility did not monitor R9 for adverse reactions or side effects of bumetanide. R22 was prescribed furosemide (a diuretic medication) for hypertension. The facility did not monitor R22 for adverse reactions or side effects of furosemide. Findings include: The facility did not provide a Medication Monitoring/Medication Management Policy. 1. On 6/26/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including respiratory failure, CHF, diabetes, and CKD. R9's admission Minimum Data Set (MDS) assessment, dated 9/15/23, indicated R9 received diuretic medication. R9's medical record indicated R9 was prescribed bumetanide 4 mg (milligrams) twice daily on 6/7/24 for CHF and CKD. Surveyor noted R9's plan of care contained interventions for daily weights, to call cardiology with a weight gain of 5 pounds in a week, a fluid restriction, lab monitoring, and hydration monitoring; however, R9's plan of care did not contain monitoring interventions for adverse reactions or side effects of bumetanide. On 6/26/23 at 10:28 AM, Surveyor interviewed Director of Nursing (DON)-B who verified side effects of bumetanide include orthostatic hypotension, hyponatremia (low blood sodium), hypokalemia (low potassium level), chest pain, cramp, dizziness, weakness, and confusion. DON-B verified although some interventions were in place there were no specific monitoring interventions for adverse reactions or side effects of bumetanide in R9's orders or care plan. 2. On 6/26/24, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] with diagnoses including dementia, lupus, CKD, and hypertension. R22's Annual MDS assessment, dated 11/10/23, indicated R22 was prescribed diuretic medication. R22's medical record indicated R22 was prescribed furosemide 40 mg once daily for hypertension on 8/29/23. Surveyor noted R22's plan of care did not contain monitoring interventions for adverse reactions or side effects of furosemide. On 6/26/24 at 11:54 AM, Surveyor interviewed DON-B who verified R22's plan of care did not contain monitoring for adverse reactions or side effects of furosemide. DON-B verified the side effects of furosemide include orthostatic hypotension, hyponatremia, hypokalemia, blurred vision, skin photosensitivity, anorexia, headache, cramps, drowsiness, dizziness, and muscle spasms. DON-B stated staff do nursing assessments, but the assessments do not indicate they are completed for diuretic monitoring.

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. DM-D stated DM-D had access to an RD via phone and email, but the RD did not work onsite due to COVID-19. DM-D stated the RD came to the facility last month for training, but that was the first time DM-D saw the RD. On 6/24/24 at 2:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A would contact their food service vendor to find out what training DM-D was enrolled in. On 6/26/24 at 2:16 PM, NHA-A stated DM-D was enrolled in a ServeSafe course of 3/19/24, but was not enrolled in another course. NHA-A confirmed DM-D was hired on 3/22/23 and verified DM-D had not completed the ServeSafe course or any further coursework to gain certification as a Dietary Manager. NHA-A provided Surveyor with proof of enrollment in an approved Dietary Manager course which DM-D was enrolled in as of 6/25/24.

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 the floor. (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under § 4-204.122. The Wisconsin Food Code documents at Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation: (A) Food shall be protected from cross contamination by: .separating raw animal foods during storage, preparation, holding, and display from: (a) Raw ready-to-eat foods including other raw animal food such as fish .or other raw ready-to-eat foods such as vegetables, and (b) Cooked ready-to-eat foods .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (a) Using separate equipment for each type, or (b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented, and (c) Preparing each type of food at different times or in separate areas .(4) .storing the food in packages, covered containers, or wrappings. The facility's Safe Food Handling policy, dated 4/4/24, indicates: .8. Food must be stored at least 18 inches above the floor. 9. Uncooked food may not be stored over cooked food. On 6/24/24 at 11:45 AM, Surveyor conducted a tour of the kitchen with Dietary Manager (DM)-D who stated the facility followed the Wisconsin Food Code. Surveyor observed a walk-in freezer with 16 boxes stacked on the floor. DM-D stated, We just got a shipment in so I will put those up (on shelves). Surveyor noted hand-written dates of 6/20 on the outside of some of the boxes. DM-D stated the hand-written dates indicated the date the boxes were delivered. DM-D confirmed some of the boxes had not just arrived and stated the boxes should be put on shelves. On 6/24/24 at 12:10 PM, Surveyor and DM-D observed a reach-in cooler that had food items stored on wire rack shelving in the following order from top to bottom: Top shelf: Beverages, pre-made eggs, and cooked pancakes Second shelf: Cooked ham and smoked bacon Third shelf: A tray of glazed pork wrapped with bacon and a cardboard box labeled Uncooked Chicken Breasts. DM-D confirmed the pork and chicken were raw/uncooked. Bottom shelf: A container of raw fish, raw ground beef loaves, and a container of cooked ham. DM-D confirmed the ham was fully cooked and the fish and beef were raw/uncooked. Following the observation, Surveyor interviewed [NAME] (CK)-E who stated raw meat should be stored on the bottom shelf but there was no room. DM-D rearranged the items and put the cooked food items above the raw meats and the uncooked chicken breasts on the bottom shelf. DM-D then instructed CK-E to place a pan under the box of uncooked chicken breasts. On 6/24/24 at 12:12 PM, Surveyor interviewed DM-D who confirmed raw meats should not be stored above cooked food.