Waters Edge Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Waters Edge Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Feb 22, 2024

  Based on policy review, Centers for Disease Control (CDC) recommendation review, observation, interview, and record review, the facility failed to ensure appropriate infection control practices as evidenced by the failure to ensure PPE (personal protective equipment) use during COVID outbreak testing for 2 of 2 sampled residents observed, Residents #1 and #11; failed to fully implement their Enhanced Barrier Precautions (EBP) policy for 3 of 3 sampled residents who were not on EBP (Residents #2, #17, and #138), and 2 additional random residents (Residents #25 and #188); failed to implement appropriate infection prevention practices for eye drop administration and blood glucose monitoring for 3 of 7 sampled residents observed during the medication pass observation, Resident #3, #18 and #28;… […]

• No harm, potential for more than minimal, patternF657Sep 10, 2021

  Based on record review and interview, the facility failed to include required point of care staff in the development of care plans for 12 of 15 residents reviewed for care planning, Residents #7, #14, #1, #25, #19, #5, #25, #12, #9, #2, #17 and #10; and failed to review 1 of 15 resident's care plan at least quarterly, Resident #14. The findings included: The facility's policy, titled Care Planning - Interdisciplinary Team, revised September 2013, documented, in Section 2, the care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not limited to the following personnel: a. The resident's Attending Physician; b. the Registered Nurse who has responsibility for the resident; c. […]

• No harm, potential for more than minimal, isolatedF880May 30, 2025

  Based on observation, interview, and record review, the facility failed to implement their infection control program as evidenced by failure to use Personal Protective Equipment (PPE) while providing care for 1 of 1 sampled residents on Enhanced Barrier Precautions (EBP) observed for catheter care, Resident #29. The findings included: Review of the Centers for Disease Control and Prevention (CDC) guidance recommends wearing PPE for resident on EBP. The article titled Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) states, Enhanced Barrier Precautions [EBP] are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact… […]

• No harm, potential for more than minimal, isolatedF695Feb 22, 2024

  Based on observation, interview, record review, and policy review, the facility failed to ensure appropriate respiratory assessment or knowledge of possible medication side effects for 1 of 1 sampled resident, Resident #24, who received a nebulizer treatment. The findings included: Review of the policy, titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, documented, in part, Steps in the Procedure: . 6. Obtain baseline pulse, respiratory rate and lung sounds. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment. 26. […]

• No harm, potential for more than minimal, isolatedF656Nov 15, 2022

  Based on record review and interview, the facility failed to ensure care plans were developed for activities and anticoagulant for 3 of 11 sampled residents, Resident #8, Resident #24 and Resident#12, reviewed for care plans. The findings included: 1. Review of Resident #8's records revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS (Minimum Data Set) documented the resident did not have a Brief Interview for Mental Status (BIMS) Score, indicating the resident's cognition was severely impaired. Review of Resident #8's progress notes documented: activities is spending 1:1 time with the resident. Review of the care plans revealed he did not have a care plan for activities. 2. […]