Water's Edge Center for Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Water's Edge Center for Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 3, 2024

  Based on observation, record review and interviews for 1 of 4 residents (Resident #78) who was on a secured locked unit and wore a wander guard, the facility failed to ensure the residents wander guard was changed when it expired, failed to investigate and implement interventions after Resident #78 was able to exit the secured locked unit on [DATE]; and failed to provide adequate supervision and devices to prevent the resident from exiting the secured locked unit on [DATE] when the resident accessed the elevator on the 4th floor, (secured locked unit), took the elevator to the 1st floor, and walked out the front door unsupervised. These failures resulted in a finding of Immediate Jeopardy. […]

• Actual harm, isolatedF600Mar 25, 2026

  Based on clinical record review, interviews, and facility documentation for 1 of 5 residents reviewed for abuse (Resident #22), the facility failed to protect the resident from repeated non consensual physical/sexual contact by another resident (Resident #129) despite a known history of prior sexual abuse between the same residents. The facility failed to implement required safety interventions, ensure effective 1:1 supervision, separate the residents as care planned, or follow its Abuse and Sexual Interaction policies, resulting in actual harm to Resident #22. […]

• Actual harm, isolatedF689Mar 5, 2026

  The facility failed to provide adequate supervision and implement effective fall prevention interventions for a cognitively impaired resident with incontinence and a known fall risk, resulting in two (2) unwitnessed falls with major injuries (right and left humerus fractures). The findings include:Resident #1 was admitted to the facility with diagnoses that included osteoarthritis of the knee, anxiety and Alzheimer's dementia. Resident #1 had a conservator of person and estate.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), was frequently incontinent of bowel and bladder and was not currently on a toileting program.The Resident Care Plan (RCP) dated 12/2/25 identified Resident #1 had a… […]

• Actual harm, isolatedF689Jul 30, 2025

  Based on clinical record review, facility documentation review, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure care was provided in accordance with the plan of care. The failure resulted in a fall with injury. The findings include: Resident #1‘s diagnoses included cerebral infarction (stroke) and morbid obesity. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition and was dependent on staff for bed mobility and transfers. The Resident Care Plan (RCP) dated 4/16/2025 identified that Resident #1 a deficit related to deconditioning and weakness. […]

• No harm, potential for more than minimal, patternF584Jul 3, 2024

  Based on observation, review of facility documentation, job descriptions, and interviews for 5 of 5 units, the facility failed to ensure the environment was clean, sanitary, maintained in good repair and homelike. The findings included: Review of the maintenance repair log dated 4/2/24 through 6/28/24 failed to reflect documentation regarding the condition of resident rooms. Review of the environmental rounds worksheet for infection prevention dated 6/26/24 and the random environmental rounds form dated 6/27/24 identified rounds were completed by RN #1. […]