Inspection Reports for Waters Edge Health and Rehabilitation Center
WI, 53140
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
29 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
530% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
103 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 12
Sep 30, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, environmental concerns, and quality of care issues at Waters Edge Health and Rehabilitation Center.
Findings
The facility failed to provide a safe, clean, and homelike environment, did not prevent or properly investigate multiple resident-to-resident abuse incidents, failed to timely report abuse allegations to the State Survey Agency, did not provide appropriate treatment and care for pressure injuries, failed to provide timely therapy services, and did not maintain an effective pest control program. Staff reported fear of retaliation and inadequate training on dementia care. Immediate Jeopardy was identified and later removed after corrective actions.
Complaint Details
The complaint investigation revealed multiple allegations of abuse, neglect, environmental hazards, and quality of care issues. The facility failed to report abuse allegations timely to the State Survey Agency and law enforcement, did not thoroughly investigate abuse incidents, and staff reported fear of retaliation. Immediate Jeopardy was identified related to abuse and was removed after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 4
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility did not provide a safe, clean, comfortable, and homelike environment; housekeeping services were inadequate with resident rooms not cleaned daily and odors present. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to protect residents from verbal, physical, and sexual abuse, including multiple incidents involving resident R89 and others on the dementia unit, with inadequate supervision and failure to prevent further incidents. | Level of Harm - Immediate jeopardy to resident health or safety |
| Facility failed to timely report allegations of abuse to the State Survey Agency and did not thoroughly investigate multiple abuse incidents involving residents R110, R89, R26, R106, R121, R122, R39, R69, and R116. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not timely report and thoroughly investigate allegations of abuse (sexual, physical, and verbal) and did not take proactive steps to prevent further potential abuse on the dementia unit affecting 30 residents. | Level of Harm - Immediate jeopardy to resident health or safety |
| Facility did not incorporate recommendations from the Pre-admission Screening and Resident Review (PASARR) Level 2 determination into resident R11's assessment, care planning, and transitions of care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure R60 received assistance with repositioning as requested, resulting in discomfort and tearful behavior. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure residents R11, R41, R60, and R90 received adequate supervision and assistance devices to prevent falls; fall investigations and RN assessments were incomplete or missing. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure residents R101, R131, and R50 received necessary care and treatment for infections, wounds, and pressure injuries in a timely and appropriate manner. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure residents environment was free from flies and did not maintain an effective pest control program. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure irregularities noted by the pharmacist during Medication Regimen Review were acted upon timely for residents R11 and R60. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure therapy services were provided in a timely manner for residents R11 and R50. | Level of Harm - Minimal harm or potential for actual harm |
| Facility was not administered in a manner that enabled it to use its resources effectively and efficiently, failing to promote the highest practicable mental and psychosocial well-being of residents, especially on the dementia unit, with multiple failures in abuse prevention, staff training, and investigation. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Resident census: 103
Grievances regarding cleanliness: 11
Falls: 17
Pressure injury measurements: 0.8
Pressure injury measurements: 0.4
Pressure injury measurements: 0.1
Medication use count: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anon-Q | Anonymous Staff | Reported sexual abuse incident involving R89 and R110, provided written statement, and expressed fear of retaliation. |
| NHA-A | Nursing Home Administrator | Informed of Immediate Jeopardy, responsible for reporting abuse allegations, interviewed multiple times regarding abuse investigations and reporting failures. |
| DON-B | Director of Nursing | Informed of Immediate Jeopardy, involved in abuse investigations, interviewed regarding care plans, therapy follow-up, and fall investigations. |
| LPN-Y | Licensed Practical Nurse | Reported housekeeping issues and assisted with resident repositioning after Surveyor intervention. |
| CNA-Z | Certified Nursing Assistant | Reported housekeeping issues and fly problem in the facility. |
| Housekeeper-AA | Housekeeper | Reported housekeeping staffing and cleaning issues. |
| District manager-BB | District Manager | Reported housekeeping expectations and follow-up. |
| Anon-P | Anonymous Staff | Reported sexual abuse concerns and staff overload on dementia unit. |
| Anon-R | Anonymous Staff | Reported fear of retaliation and physical aggression by R89. |
| Psych-C | Psychologist | Provided psychiatric consultation and commented on lack of staff training. |
| Wound Nurse-EE | Wound Nurse | Provided wound assessments and treatment information for residents. |
| Therapy Director-VV | Therapy Director | Interviewed about therapy delays and evaluation processes. |
Inspection Report
Routine
Deficiencies: 14
Sep 30, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident privacy, property protection, transfer and discharge notifications, care planning, activities of daily living, code status documentation, fall prevention, respiratory care, dialysis care, medication regimen review, medication labeling and storage, infection control, and immunization practices.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy and confidentiality, misappropriation of resident property, inadequate transfer and discharge notifications, incomplete and inaccurate care plans, failure to provide timely therapy services, medication errors, improper medication storage and labeling, inadequate infection control practices, and incomplete documentation of immunizations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure privacy and confidentiality for 12 of 20 residents, including unattended medication carts displaying personal health information and lack of privacy during enteral feeding tube medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to prevent misappropriation of resident R9's personal cell phone by a housekeeper. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide proper transfer/discharge and bed hold notices to residents and their representatives, and failure to notify the Ombudsman for 7 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop accurate and complete care plans for residents R11 and R90, including missing interventions for pressure injury and pleasure feedings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide assistance with activities of daily living and repositioning for resident R60, resulting in discomfort and potential harm. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure physician orders for code status were current and documented for resident R11. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and fall prevention interventions for residents R60, R11, R41, and R90, including incomplete fall investigations and lack of RN assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care for resident R49, including oxygen flow rate not matching physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate dialysis care for resident R3, including missing physician orders for dialysis access monitoring and care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure pharmacist medication regimen review irregularities were communicated and acted upon for residents R11 and R60. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label drugs and biologicals properly and store medications securely, including undated insulin pens, unlabeled eye drops, loose pills in medication carts, and unlabeled blood glucose test strips. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely therapy services for residents R11 and R50, including delayed therapy evaluations and treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program, including lack of hand hygiene during medication administration, failure to wear appropriate PPE during high-contact care for residents on enhanced barrier precautions, improper disinfection of glucometers, and uncovered Foley catheter drainage bag on the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly document COVID-19 vaccination status for residents R9, R11, and R12, including lack of documentation of offers, refusals, or administration of vaccine. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 8
Falls: 17
Medication use: 10
Insulin dose: 625
Medication doses: 6
Medication doses: 3
Medication doses: 30
Medication doses: 400
Medication doses: 15
Medication doses: 250
Medication doses: 50
Medication doses: 30
Medication doses: 1
Medication doses: 625
Medication doses: 600
Medication doses: 30
Medication doses: 81
Medication doses: 40
Medication doses: 5
Medication doses: 12.5
Medication doses: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-KK | Licensed Practical Nurse | Named in privacy and confidentiality deficiency and medication administration without appropriate PPE |
| Housekeeper-PP | Named in misappropriation of resident property finding | |
| DON-B | Director of Nursing | Named in multiple findings including privacy, transfer notices, care planning, medication follow-up, infection control |
| NHA-A | Nursing Home Administrator | Named in multiple findings including misappropriation investigation, transfer notices, medication follow-up, infection control |
| SW-D | Social Worker | Named in misappropriation investigation and guardianship process |
| RD-RRR | Registered Dietitian | Named in care plan deficiency for pleasure feedings |
| LPN-Y | Licensed Practical Nurse | Named in medication storage and labeling deficiency |
| RN-LL | Registered Nurse | Named in medication administration and infection control deficiencies |
| UM-F | Unit Manager / Infection Preventionist | Named in infection control and immunization documentation deficiencies |
| RN-OO | Registered Nurse | Named in dialysis care deficiency |
| CP-NNN | Consultant Pharmacist | Named in medication regimen review deficiency |
| TD-VV | Therapy Director | Named in therapy services delay deficiency |
| NP-K | Nurse Practitioner | Named in guardianship and medication follow-up deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding nursing staff competencies and medication administration errors, specifically involving insulin administration to a resident.
Findings
The facility failed to ensure nursing staff had appropriate competencies, resulting in a medication error where a resident was given an incorrect insulin dose. The resident did not experience adverse effects, and the facility implemented education and competency check-offs for nurses.
Complaint Details
The complaint investigation found that Licensed Practical Nurse (LPN)1, a recent graduate in training, administered 15 units of lispro insulin instead of the prescribed 4 units to Resident 7. The error was immediately reported, and monitoring showed no adverse effects. The facility lacked documented orientation and skills check-offs prior to LPN1 working independently. The facility has since implemented education and competency assessments for nurses.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Level of Harm - Minimal harm or potential for actual harm |
| Ensure that residents are free from significant medication errors. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident sample size: 15
Insulin dose error: 15
Correct insulin dose: 4
Blood sugar reading: 185
Orientation requested: 12
Assessment Reference Date: Jun 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Administered incorrect insulin dose; recent nursing school graduate in training |
| LPN2 | Licensed Practical Nurse | Provided orientation and support to LPN1 during the shift with nurse call-off |
| Administrator | Provided information about orientation practices and follow-up actions | |
| Medical Director | Commented on insulin error and facility response | |
| Director of Nursing | DON | Involved in notification and medication error counseling |
Inspection Report
Routine
Deficiencies: 1
Jul 8, 2025
Visit Reason
The inspection was conducted to assess the facility's adherence to infection prevention and control practices, specifically related to wound care and use of Enhanced Barrier Precautions (EBP).
Findings
The facility failed to adhere to infection control policies during wound care by not wearing gowns as required for residents on Enhanced Barrier Precautions, increasing the risk of cross contamination and infections.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to wear gowns during wound care for a resident on Enhanced Barrier Precautions, increasing risk of cross contamination and infections. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Named in wound care infection control deficiency for not wearing gown |
| LPN2 | Licensed Practical Nurse | Named in wound care infection control deficiency for not wearing gown |
| Director of Nursing | Director of Nursing | Provided statement on infection control expectations |
Inspection Report
Routine
Deficiencies: 1
May 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the availability of clean linen for resident care in the facility.
Findings
The facility failed to ensure a sufficient supply of clean linen was readily available in three of four linen closets on two floors, causing delays in resident care such as bathing and incontinence care. Staff and residents reported frequent shortages of towels and washcloths, leading to delays and residents stockpiling linens.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a sufficient supply of clean linen was readily available for resident care in three of four linen closets on two floors. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Towels in South Unit linen closet: 6
Washcloths in South Unit linen closet: 1
Towels in small cart in South Unit linen closet: 5
Towels in North Unit linen closet (second floor): 7
Washcloths in North Unit linen closet (second floor): 0
Washcloths in North Unit linen closet (first floor): 8
Towels in North Unit linen closet (first floor): 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 5 | CNA | Reported linen shortages causing delays in resident care |
| Certified Nursing Assistant 6 | CNA | Reported linen shortages causing delays in resident care |
| Certified Nursing Assistant 7 | CNA | Reported linen shortages causing delays in resident care |
| Licensed Practical Nurse 2 | LPN | Reported problems with insufficient laundry causing delays in resident care |
| Laundry Manager | Housekeeping Manager | Reported no recent concerns with linen availability and described linen delivery schedule |
| Director of Nursing | DON | Stated no policy exists for maintaining sufficient laundry for resident use |
| Administrator | Administrator | Reported daily counting of linen and ability to order more as needed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 30, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident at Waters Edge Health and Rehabilitation Center. The visit aimed to assess the facility's compliance with accident prevention and supervision policies after a resident experienced a fall resulting in significant injuries.
Findings
The facility failed to ensure a safe environment and adequate supervision for one resident who fell from bed while being cared for by a staff member, resulting in a broken hip and a large laceration requiring staples. The investigation revealed that the staff member did not follow the resident's care plan, which required assistance from two staff members for bed mobility, contributing to the fall and injuries.
Complaint Details
The complaint investigation was substantiated. The resident fell from bed on 09/09/24 while a Certified Nursing Assistant (CNA1) was providing care without the required assistance of a second staff member, contrary to the resident's care plan. This failure led to a fractured right femur and a laceration to the head requiring emergency treatment and surgery.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident fall with significant injuries. | Level of Harm - Actual harm |
Report Facts
Fall risk score: 12
Staples required: 9
Date of fall: Sep 9, 2024
Date of surgery: Sep 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Named in the finding for not following the resident's plan of care during provision of care leading to the fall. |
| Administrator | Interviewed and confirmed expectation that staff follow resident care plans. | |
| Director of Nursing | DON | Interviewed and confirmed expectation that staff follow resident care plans. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 11, 2024
Visit Reason
The inspection was conducted following complaints from a resident's family member regarding inadequate incontinence care and alleged failure to provide care on a specific date, 7/19/24.
Findings
The facility failed to submit a required facility self-report investigation to the State Agency within the mandated 5 working days, submitting it late on 8/21/24. The investigation found no identified concerns with care provision on 7/19/24, and the resident was observed to be well-groomed and in no distress during the survey.
Complaint Details
The complaint investigation was triggered by concerns expressed by R2's family member on 7/21/24 and 8/5/24 regarding incontinence care and alleged failure to provide care on 7/19/24. The facility's investigation was submitted late to the State Agency on 8/21/24 instead of within 5 working days. The Nursing Home Administrator acknowledged the late submission and explained technical difficulties with the submission process.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure 1 of 2 Facility Self Report investigations was reported to the State Agency as required within 5 working days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days late for investigation submission: 11
Date of inspection: Sep 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding responsibility for submitting Facility Self Reports and acknowledged late submission of the 5-day investigation report. |
Inspection Report
Routine
Deficiencies: 4
Aug 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and food service at Waters Edge Health and Rehabilitation Center.
Findings
The facility was found deficient in ensuring residents had properly fitting bed linens, appropriate pressure ulcer care, adequate supervision during meals to prevent choking, and proper preparation of pureed diets according to recipes. Deficiencies involved minimal harm or potential for actual harm affecting a few residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Residents did not have bed linens in good condition that properly fit the bed, specifically one resident (R23) had a fitted sheet that did not cover the entire mattress. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure residents received appropriate pressure ulcer care and prevention, including failure to revise care plans and treatment orders after a resident (R61) developed blisters from hand splints. | Level of Harm - Minimal harm or potential for actual harm |
| A resident (R37) requiring supervision during meals to prevent choking was observed eating unsupervised. | Level of Harm - Minimal harm or potential for actual harm |
| Food was not prepared to conserve nutritive value and flavor; the cook did not follow recipes for pureed food preparation affecting 13 residents on pureed diets. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for bed linens: 19
Residents reviewed with pressure injuries: 9
Residents on pureed diet affected: 13
Braden score: 11
Medication administration record start date: Jun 28, 2023
TAR order start date: Jun 28, 2023
Date of observation of bed linen issue: Jul 29, 2024
Date of observation of meal supervision issue: Aug 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Received observations regarding bed linen and pressure ulcer care deficiencies |
| Director of Nursing B | Director of Nursing | Received observations regarding bed linen, pressure ulcer care, and meal supervision deficiencies |
| Certified Nursing Assistant M | Certified Nursing Assistant | Observed interacting with resident R23 and bed linens |
| Laundry Manager N | Laundry Manager | Interviewed regarding availability of bariatric fitted sheets |
| Wound MD V | Wound Physician | Interviewed regarding cause of blisters on resident R61's hand |
| Wound Nurse S | Wound Nurse | Interviewed regarding care recommendations for resident R61 |
| Rehab Manager I | Rehabilitation Manager | Interviewed regarding splinting and palm guard use for resident R61 |
| Licensed Practical Nurse Q | Licensed Practical Nurse | Interviewed regarding splinting care for resident R61 |
| Certified Nursing Assistant P | Certified Nursing Assistant | Interviewed regarding meal supervision for resident R37 |
| Unit Manager G | Unit Manager | Interviewed regarding meal supervision for resident R37 |
| Cook C | Cook | Observed preparing pureed food without following recipes |
| Food Service Director D | Food Service Director | Interviewed regarding pureed food preparation and recipe adherence |
Inspection Report
Routine
Deficiencies: 11
Aug 5, 2024
Visit Reason
The inspection was a routine survey of Waters Edge Health and Rehabilitation Center to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The survey identified multiple deficiencies including improper bed linen fitting, delayed significant change assessments, inaccurate PASRR coding, inadequate hearing services, pressure ulcer care issues, improper use of hand splints, lack of supervision during meals, improper catheter care, enteral feeding regimen inconsistencies, staffing schedule issues, and failure to follow pureed diet recipes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Level of Harm - Potential for minimal harm: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Residents did not have bed linens in good condition that properly fit the bed, specifically one resident (R23) had a fitted sheet that did not cover the entire mattress. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not complete a significant change in status assessment MDS for one resident (R59) when enrolled in hospice care. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure assessments accurately reflected residents' PASRR status for five residents (R37, R7, R60, R48, and R41). | Level of Harm - Potential for minimal harm |
| The facility did not ensure one resident (R84) received proper treatment and assistive device to maintain hearing abilities; audiology consults were delayed. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not provide appropriate pressure ulcer care for one resident (R61) who developed blisters from hand splints; care plans and orders were not revised timely. | Level of Harm - Minimal harm or potential for actual harm |
| One resident (R36) with limited range of motion was not provided appropriate splinting treatment as ordered; splint was missing and not applied. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure supervision during meals for one resident (R37) requiring supervision to prevent choking; resident was observed eating unsupervised. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure appropriate catheter care for one resident (R63); staff used improper technique during catheter care. | Level of Harm - Minimal harm or potential for actual harm |
| Residents fed by enteral means (R23 and R36) did not receive appropriate services to prevent complications; feeding orders were inconsistent with actual administration and dietitian documentation. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure a charge nurse was assigned for each shift on staffing schedules, affecting oversight of nursing care. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure food was prepared following recipes for pureed diets, risking nutritive value and flavor for 13 residents on pureed diets. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for bed linens: 19
Weight loss: 16.4
Residents on pureed diet: 13
Braden score: 11
Tube feeding frequency: 5
Tube feeding frequency: 7
Free water flush volume: 320
Residents reviewed for catheter care: 5
Residents reviewed for enteral feeding: 4
Residents in facility: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA-M | Certified Nursing Assistant | Observed and interviewed regarding bed linen fitting for resident R23 |
| Laundry Manager N | Laundry Manager | Interviewed regarding availability and use of bariatric fitted sheets |
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed and informed about multiple deficiencies including bed linens, feeding, and staffing |
| Director of Nursing B | Director of Nursing | Interviewed and informed about multiple deficiencies including assessments, feeding, and staffing |
| MDS Coordinator U | MDS Coordinator | Interviewed regarding significant change MDS completion |
| MDS-O | MDS Coordinator | Interviewed regarding PASRR coding issues |
| NHA-A | Nursing Home Administrator | Interviewed regarding hearing services and feeding supervision |
| LPN-Q | Licensed Practical Nurse | Interviewed regarding hand splinting care for resident R61 |
| Wound MD-V | Wound Physician | Interviewed regarding pressure ulcer/blister causation for resident R61 |
| Wound Nurse-S | Wound Nurse | Interviewed regarding pressure ulcer/blister care for resident R61 |
| Rehab Manager I | Rehabilitation Manager | Interviewed regarding hand splinting for resident R61 |
| CNA-L | Certified Nursing Assistant | Interviewed regarding hand splint use for resident R36 |
| RD-K | Registered Dietitian | Interviewed and documented nutritional care for resident R23 |
| RD-J | Registered Dietitian | Interviewed regarding enteral feeding and hydration for residents R23 and R36 |
| CNA-T | Certified Nursing Assistant | Observed providing catheter care for resident R63 |
| Cook-C | Cook | Observed preparing pureed food without following recipes |
| FSD-D | Food Service Director | Interviewed regarding pureed diet preparation and recipes |
| Scheduler-E | Scheduler | Interviewed regarding nursing charge nurse assignments on schedules |
| UM-G | Unit Manager | Interviewed regarding meal supervision for resident R37 |
| LPN-H | Licensed Practical Nurse | Interviewed regarding hydration monitoring and splinting for residents R23 and R36 |
Inspection Report
Routine
Deficiencies: 12
May 20, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, resident council activities, admission agreements, abuse reporting, pressure ulcer care, activities of daily living, respiratory care, nutrition, safety, and medical record safeguarding at Waters Edge Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to share a room, inadequate resident council grievance follow-up, lack of signed admission agreements for many residents, delayed and incomplete reporting of abuse allegations, failure to notify mental health authorities timely, inadequate care for pressure injuries, insufficient supervision to prevent accidents, failure to provide appropriate catheter and bowel care, failure to maintain acceptable nutritional status, and failure to safeguard confidential medical records.
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility did not ensure that married residents R7 and R16 were allowed to share a room after both consented. | — |
| Facility did not ensure grievances and recommendations from Resident Council meetings were acted upon promptly and did not demonstrate response or rationale. | — |
| Facility failed to obtain signed admission agreements for 40 residents, including R1 who refused to sign until day before discharge. | — |
| Facility failed to report 3 of 4 incidents of abuse, neglect, or theft to the State survey agency and/or Nursing Home Administrator within required timeframes. | — |
| Facility did not notify the state mental health authority promptly after a significant change in mental illness for resident R6. | — |
| Facility did not provide necessary ADL services for resident R4, including failure to keep nails short as per care plan. | — |
| Facility did not ensure residents R3 and R9 received treatment and care according to professional standards and care plans, including delayed wound treatment and incomplete assessments. | Immediate jeopardy |
| Facility did not have identified safety devices or supervision in place to prevent falls or incidents requiring increased supervision for residents R4 and R6. | — |
| Facility did not ensure appropriate catheter care and bowel management for resident R9, resulting in urinary tract infections and bowel incontinence without a comprehensive care plan. | — |
| Facility did not ensure residents R3 and R10 maintained acceptable nutritional status, including failure to obtain weights per facility guidelines. | — |
| Facility did not ensure resident R4 had oxygen administered according to physician orders. | — |
| Facility did not safeguard confidential medical records properly; records were stored in open cardboard boxes on the floor below a fire sprinkler, risking loss or damage. | — |
Report Facts
Residents without signed admission agreements: 40
Grievances without resident names: 30
Pressure injury measurement: 9.55
Pressure injury measurement: 7.95
Pressure injury measurement: 0.1
Pressure injury measurement: 8.77
Pressure injury measurement: 7.22
Pressure injury measurement: 3
Weight difference: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Interviewed regarding delayed abuse reporting, admission agreements, and other deficiencies. |
| DON-B | Director of Nursing | Interviewed regarding wound care, supervision, nutritional monitoring, and other deficiencies. |
| RCC-E | Resident Care Coordinator | Interviewed regarding admission agreements and resident council. |
| Wound RN-X | Wound Registered Nurse | Interviewed regarding wound assessments and treatments. |
| LPN-W | Licensed Practical Nurse | Wrote nurse notes related to resident behaviors and care. |
| LPN-KK | Licensed Practical Nurse | Wrote nurse notes related to resident altercations and behaviors. |
| DSS-H | Director of Social Services | Interviewed regarding grievances and PASARR submission. |
| SW-I | Social Worker | Interviewed regarding resident behaviors and room sharing. |
| LPN-AA | Licensed Practical Nurse | Involved in medication discrepancy reporting. |
Inspection Report
Routine
Deficiencies: 5
Dec 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, abuse prevention, discharge planning, and wound care at Waters Edge Health and Rehabilitation Center.
Findings
The facility failed to notify physicians timely about changes in resident conditions, ensure proper wound care treatments were administered as ordered, prevent resident-to-resident abuse, and follow discharge planning policies including notification of physicians and Adult Protective Services when residents left Against Medical Advice (AMA).
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to notify physician of need to alter treatment for a pressure ulcer for Resident 9. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect Resident 8 from resident-to-resident physical abuse by Resident 7. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow discharge planning process including notifying physician and APS when residents left AMA for Residents 6, 1, and 10. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide ordered non-pressure wound treatment to Resident 2. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide ordered pressure ulcer treatment to Resident 9. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for discharge: 16
Residents reviewed for non-pressure wounds: 3
Residents reviewed for pressure injuries: 2
Residents affected by deficiencies: 5
Wound size: 4.8
Wound size: 7.3
Wound size: 3.7
Wound vacuum pressure: 125
Wound vacuum pressure: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in failure to notify physician and document removal of wound vacuum for Resident 9. |
| RN2 | Registered Nurse | Assigned to Resident 9 on 12/05/23, did not receive shift report about wound vacuum removal. |
| CNA7 | Certified Nurse Aide | Witnessed resident-to-resident abuse incident between Residents 7 and 8. |
| CNA8 | Certified Nurse Aide | Provided supervision after resident-to-resident abuse incident. |
| LPN1 | Licensed Practical Nurse | Reported resident-to-resident abuse to Administrator and DON. |
| Administrator | Facility Administrator | Involved in abuse incident response and discharge planning interviews. |
| DON | Director of Nursing | Involved in wound care oversight, abuse incident response, and discharge planning. |
| SSD | Social Services Director | Involved in discharge planning and abuse incident follow-up. |
| NP1 | Nurse Practitioner | Notified about discharge AMA after the fact, confirmed lack of notification. |
| NP2 | Nurse Practitioner | Documented concerns about Resident 10 leaving AMA, not notified timely. |
| MDSC | Minimum Data Set Coordinator | Covered unit briefly, did not complete wound care or notify next shift. |
| LPN4 | Licensed Practical Nurse | Assigned to Resident 9, unaware of wound vacuum removal. |
| CNA9 | Certified Nurse Aide | Assigned to Resident 9, unaware of wound vacuum removal. |
| CNA10 | Certified Nurse Aide | Reported wound vacuum removal to RN1. |
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, specialized services coordination, and treatment adherence at Waters Edge Health and Rehabilitation Center.
Findings
The facility failed to ensure call lights were within reach for 2 residents, did not incorporate specialized services into the plan of care for 1 resident, and delayed wound treatment for 1 resident, resulting in minimal harm or potential for harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Call lights were not within reach for 2 residents (R1 and R4) despite care plans indicating they should be accessible. | Level of Harm - Minimal harm or potential for actual harm |
| Specialized services recommended by PASRR Level II for resident R1 were not incorporated into the plan of care or transition of care. | Level of Harm - Minimal harm or potential for actual harm |
| Delayed wound treatment for resident R1; treatment orders from 1/4/23 were not implemented until 1/16/23. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 17
Residents sampled: 6
Residents sampled: 1
Delay in treatment days: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse D | Registered Nurse | Verified R1 should have a pressure sensitive call light |
| Certified Nursing Assistant C | Certified Nursing Assistant | Stated R1's call light was connected to the wall and should be pressure sensitive |
| Unit Manager E | Unit Manager | Planned audit due to call light not within reach for R1 |
| Nursing Home Administrator A | Nursing Home Administrator | Verified lack of admission assessment for call light use and delay in wound treatment |
| Licensed Practical Nurse I | Licensed Practical Nurse | Verified R4's call light should be within reach |
| Certified Nursing Assistant H | Certified Nursing Assistant | Indicated R1 was not often up in wheelchair and never attended activities |
| Activity Aide F | Activity Aide | Described activities provided to R1 and lack of attendance outside room |
| Social Services Director G | Social Services Director | Agreed to coordinate nursing and activities for R1 |
| Wound Nurse J | Wound Nurse | Verified wound treatment orders and delay in treatment for R1 |
| Wound Physician K | Wound Physician | Provided wound treatment orders and expected staff to complete treatments |
Inspection Report
Complaint Investigation
Deficiencies: 4
May 24, 2023
Visit Reason
The inspection was conducted based on complaints regarding grievances not being fully investigated and followed up, inadequate oral hygiene with prescribed toothpaste, failure to provide incontinence care, and failure to address nutritional needs and weight loss in residents.
Findings
The facility failed to ensure grievances were fully investigated and resolved for one resident, did not provide prescribed oral hygiene for another resident, failed to provide timely incontinence care during repositioning, and did not adequately monitor and address significant weight loss and nutritional needs for a resident with a gastrostomy tube.
Complaint Details
The complaint investigation focused on grievances not being fully addressed for resident R12, inadequate oral hygiene with prescribed toothpaste, failure to provide incontinence care for residents R12 and R88, and failure to address nutritional needs and weight loss for resident R75. The grievance for R12 was not followed up to ensure satisfaction. R12 was not receiving prescribed toothpaste despite orders. R88 was repositioned without incontinence care despite fecal odor. R75 experienced significant weight loss that was not properly monitored or addressed in a timely manner.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to fully investigate and follow up on resident grievances to ensure resolution. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide oral hygiene twice daily with physician-ordered prescription toothpaste. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide incontinence care at the time of repositioning despite odor of feces being present. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to recognize, evaluate, and address significant weight loss and nutritional care needs, including failure to reweigh resident and implement recommended tube feeding increases timely. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 4
Weight loss percentage: 12
Tube feeding rate increase: 120
Prescription toothpaste refills: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M | Social Worker | Interviewed about grievance process and follow-up for resident R12. |
| A | Nursing Home Administrator | Informed of concerns regarding grievances and oral hygiene issues for resident R12 and incontinence care for resident R88. |
| B | Director of Nursing | Discussed concerns about incontinence care and weight loss management for resident R75. |
| RD-P | Registered Dietitian | Conducted nutritional assessments and recommended tube feeding increases for resident R75. |
| H | Registered Nurse Unit Manager | Interviewed about rounds and incontinence care procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 9
May 24, 2023
Visit Reason
The inspection was conducted based on complaints related to grievances not being fully investigated, inadequate personal care, medication administration issues, nutritional care concerns, medication errors, and infection control practices.
Findings
The facility failed to fully investigate and resolve resident grievances, provide adequate personal hygiene and oral care, ensure proper monitoring and care of a PICC line, address significant weight loss with timely nutritional interventions, administer medications properly including flushing feeding tubes and verifying placement, maintain medication storage and labeling standards, and implement effective infection prevention and control practices including proper PPE use and hand hygiene.
Complaint Details
The complaint investigation included grievances not being fully investigated, inadequate personal care, medication administration errors, nutritional care deficiencies, medication errors, and infection control issues.
Deficiencies (9)
| Description |
|---|
| Facility did not ensure 1 of 3 residents reviewed for grievances had their grievances fully investigated or followed up on to ensure resolution. |
| Facility did not ensure residents unable to carry out personal hygiene received incontinence care and oral hygiene for 2 of 5 residents dependent on staff. |
| Facility did not ensure 1 resident received treatments and care based on comprehensive assessment and professional standards; PICC line site was dirty, dressing rolled up, no flush orders or care plan, and conflicting discontinuation orders. |
| Facility failed to ensure 1 resident's nutritional care needs were recognized, evaluated, and addressed timely for significant weight loss; weights were missed or refused without adequate follow-up and tube feeding increases were delayed. |
| Facility did not ensure 1 resident with a gastrostomy tube received medication administration per policy; feeding tube was not flushed before and after medication and placement was not verified. |
| Facility had a medication error rate of 8% for 1 resident; two medications were omitted during medication pass. |
| Facility did not ensure 4 residents' insulin vials and 1 resident's eye drop medication were dated when opened as required. |
| Facility did not store or prepare food in accordance with professional standards; food was uncovered, unlabeled, undated, and equipment was not properly cleaned between uses. |
| Facility did not ensure an effective infection control program; staff failed to use PPE properly and did not perform hand hygiene when indicated, and medication was handled unsanitarily. |
Report Facts
Medication error rate: 8
Weight loss percentage: 12
Tube feeding rate: 120
Tube feeding volume: 1200
Tube feeding calories: 1800
Tube feeding protein: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in medication administration errors and unsanitary medication handling. |
| DON B | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, infection control, and nutritional care. |
| RD-P | Registered Dietitian | Named in nutritional care deficiencies and delayed tube feeding order implementation. |
| CNA-R | Certified Nursing Assistant | Observed not wearing gown and not performing hand hygiene during enhanced barrier precautions care. |
| DM-J | Dietary Manager | Interviewed regarding food safety and kitchen sanitation deficiencies. |
| NHA-A | Nursing Home Administrator | Informed of multiple concerns during survey. |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 7
Feb 1, 2023
Visit Reason
The inspection was conducted following a complaint investigation triggered by a positive Legionella urine antigen test in a resident (R1) who had not left the facility since August 2022, indicating a presumptive healthcare-associated case of Legionella.
Findings
The facility failed to maintain proper food service sanitation, conduct a comprehensive facility-wide assessment including infection preventionist staffing and emergency preparedness, maintain complete medical records, develop and implement an effective water management plan to prevent Legionella growth, ensure proper infection prevention and control practices including PPE use and COVID-19 vaccination, and maintain an effective Quality Assessment and Assurance committee. Immediate jeopardy was identified due to inadequate water management and infection control practices.
Complaint Details
The complaint investigation was initiated due to a positive Legionella urine antigen test in resident R1, who had not left the facility since August 2022, indicating a presumptive healthcare-associated case of Legionella. The investigation revealed multiple deficiencies related to infection control, water management, and quality assurance.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to properly sanitize kitchenware due to inconsistent monitoring of dishwashing machine temperatures and sanitizing solution levels, with a clogged sanitizer injector line. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct a facility-wide assessment to determine necessary resources for competent care during day-to-day operations and emergencies, including lack of infection preventionist role and incomplete emergency preparedness plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain complete and accurate medical records for a resident with a leaking feeding tube, including missing nursing credentials and incomplete documentation of physician orders and assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure of the Quality Assessment and Assurance Committee to develop and implement appropriate corrective plans for identified deficiencies, including water management and infection preventionist staffing, resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to establish and maintain an infection prevention and control program based on current standards, including inadequate water management plan, lack of surveillance for staff adherence to infection control policies, and improper use of PPE during aerosol generating procedures and enhanced barrier precautions. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to offer COVID-19 bivalent booster vaccine to an eligible resident despite policy requirements and CDC guidance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to designate a qualified infection preventionist with adequate time to fulfill responsibilities, resulting in inadequate management of the infection prevention and control program. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 81
Residents affected: 106
Sanitizer level: 50
Wash temperature: 120
Rinse temperature: 140
Date of survey completion: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Designated Infection Preventionist, involved in infection control deficiencies and facility assessment |
| DS-E | Dietary Supervisor | Involved in food service sanitation deficiency and dishwashing machine issues |
| Cook-R | Observed operating dishwashing machine and testing sanitizing solution | |
| LPN L | Licensed Practical Nurse | Involved in documentation deficiency related to resident feeding tube |
| RN M | Registered Nurse | Observed resident feeding tube and made late entry notes |
| RN N | Registered Nurse | Assessed resident feeding tube and made late entry notes |
| LPN F | Licensed Practical Nurse | Observed not properly using PPE during aerosol generating procedures |
| LPN I | Licensed Practical Nurse | Observed not properly using PPE during aerosol generating procedures |
| Housekeeper O | Observed improper mask use and potential cross contamination with water pitcher | |
| Housekeeper P | Observed improper mask use | |
| Maintenance Supervisor C | Involved in water management and maintenance program | |
| Corporate Maintenance Supervisor D | Involved in water management and maintenance program | |
| Contracted Plumber H | Involved in water management and facility plumbing |
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