Water's Edge

In the surveyor’s words

From the most serious findings on record at Water's Edge, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 8, 2025

  Based on record review, observation, and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (R) (R1 and R2) reviewed.The facility did not ensure R2's bed alarm was functioning to alert staff of self-transfer resulting in R2 falling and sustaining an acute fracture involving the left orbital roof, opacified left frontal sinus consistent with fracture involving its lateral wall, and a left nasal fracture. This example is being cited at actual harm.The facility did not ensure that R1 was transferred with assist of 2 and correct sling causing R1 to fall to the floor. […]

• No harm, potential for more than minimal, widespreadF880May 14, 2025

  Based on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not describe the building water systems using text and flow diagrams. This has the potential to affect all 37 residents in the facility. Findings include: Surveyor's record review of the facility's water management plan revealed a description of some areas where water was stagnated, and a record of weekly flushing of facility's stagnate water, but no text and flow diagrams were found with hotspots indicating potential hazards on the diagram. […]

• No harm, potential for more than minimal, widespreadF880Apr 24, 2024

  Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 40 residents (R). The facility did not complete surveillance for the time of onset of symptoms for COVID-19 symptomatic staff. Findings include: Surveyor requested and reviewed the facility procedure titled House Supervisor and Leader Guidance for Ill Employee Calls dated 02/19/24. […]

• No harm, potential for more than minimal, widespreadF812Mar 2, 2022

  Based on interviews and record review, the facility did not store foods in a manner that prevents foodborne illness. The correct cooling process was not being used for leftovers. This has the potential to affect all 41residents. ~The facility did not cool leftover foods using the correct process. This is evidenced by: On 2/28/2022 at approximately 10:30AM, Surveyor did initial tour of the kitchen with the Kitchen Manager (KM) C. Surveyor interviewed KM C regarding the cooling process they were doing for the foods they were using as leftovers. KM C stated they do serve leftovers. The process they use is that the staff working the afternoon shift take the food temperatures prior to putting the food in the cooler. This temperature is written on the log. […]

• No harm, potential for more than minimal, patternF812Jul 1, 2026

  The facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect 21 residents (R4, R10, R11, R12, R13, R14, R15, R16, R18, R19, R26, R27, R29, R6, R31, R32, R35, R36, R39, R40, and R41) of 39 residents on the Sunrise Bay Unit of the facility. Staff did not wear hair restraints properly while preparing food in the kitchenette.Staff did not perform hand hygiene with glove use.Staff did not consistently date or label food items when opened.Staff observed touching ready to eat food with contaminated gloves.Findings:Example 1The 2022 FDA Food Code documents at 2-402 Hair Restraints2-402.11 Effectiveness.(A) Except as provided in (B) of this section, food employees shall wear hair restraints such as… […]