Edgewater at Waterman Village

In the surveyor’s words

From the most serious findings on record at Edgewater at Waterman Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF695Jan 27, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #44 and #362, in a total sample of 30 residents. Findings: 1. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Summary: Oxygen: 2 liters via N/C [Nasal Canula] PRN [as needed] every shift and as needed. During an observation on 1/24/2022 at 10:27 AM, Resident #44 way lying in her bed receiving oxygen via nasal cannula. […]

• No harm, potential for more than minimal, isolatedF641Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 of 2 residents reviewed for positioning and mobility (Resident #19), 1 of 9 residents reviewed for medication management (Resident #3), and 1 of 6 residents reviewed for behavior/mood (Resident #1). Findings include: 1) During an observation on 3/10/2026 at 10:23 AM, there was a mechanical lift pad underneath Resident #19, who was sitting in her wheelchair. During an interview on 3/10/2026 at 10:23 AM, Resident #19 stated that she needed two-person assist for transfer from mechanical lift to wheelchair, but she could self-propel wheelchair when needed. […]

• No harm, potential for more than minimal, isolatedF656Mar 12, 2026

  Based on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 of 9 residents reviewed for medication management (Resident #3).Findings include:Review of Resident #3's progress note dated 2/2/2026 read, Insulin Glargine Solostar Subcutaneous Solution Pen injector 100 unit/ml [milliliter], Inject 15 unit subcutaneously at bedtime for DM [Diabetes Mellitus]. bg [blood glucose] 160 pt [patient] refused med stated if bg below she is not taking it.Review of Resident #3's Medication Administration Record (MAR) for February 2026 for administration of Insulin Glargine showed code 2 (Drug Refused) was documented on 2/3/2026, 2/6/2026, 2/8/2026, 2/12/2026, 2/13/2026, 2/16/2026, 2/20/2026, 2/22/2026, 2/25/2026, 2/26/2026, and 2/27/2026 at 9:00 PM. […]

• No harm, potential for more than minimal, isolatedF756Mar 12, 2026

  Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendation and failed to ensure physician's order was implemented upon pharmacist's recommendations for 2 of 9 residents reviewed for medication management (Residents #3 and #6).Findings include: 1) Review of Resident #6's consultation report with the recommendation date of 10/14/2025 read, Comment: [Resident #6's name] has a PRN [as needed] order for an anxiolytic, without a stop date: Lorazepam. Recommendation: Please discontinue PRN Lorazepam, tapering as necessary (e.g. decreasing the dose by no more than 25%, or 10-12% in high-risk residents, every 2 weeks). […]

• No harm, potential for more than minimal, isolatedF757Mar 12, 2026

  Based on record review and interview, the facility failed to ensure residents' drug regimens were free from unnecessary medications for 2 of 9 residents reviewed for medication management (Residents #3 and #77).Findings include: 1) Review of Resident #77's physician order dated 2/25/2026 read, Midodrine HCl [Hydrochloride] Oral Tablet 10 mg [milligram] (Midodrine HCl), Give one tablet by mouth every 8 hours for Hypotension, Hold for SBP [Systolic Blood Pressure] of > [higher than] 100. […]