Waters Edge Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF835Feb 1, 2023

  Based upon observation, interview, and record review, the facility was not administered in a manner to ensure residents attained or maintained their highest level of practicable well-being. This deficient practice had the potential to affect all 106 residents residing in the facility at the time of the survey. During a complaint survey conducted on 1/26/23 - 2/1/23, it was determined 8 deficiencies existed including the deficient practice at F835 (Administration.) Each of the deficiencies identified systemic issues within the facility that were not addressed by facility administration through established processes. Three of the deficiencies have been identified to be deficient at a severity level of immediate jeopardy and at a scope of either pattern or widespread. […]

• Immediate jeopardy, widespreadF867Feb 1, 2023

  Based on interview and record review, the facility's Quality Assessment and Assurance Committee did not develop and implement appropriate plans of action to correct identify quality deficiencies. This has the potential to affect all 106 residents residing at the facility. The Quality Assessment and Assurance (QAA) Committee did not develop and implement appropriate plans of action for identified deficiencies related to the need to create a comprehensive Facility Assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. […]

• Immediate jeopardy, widespreadF880Feb 1, 2023

  Based on observations, interviews, and record reviews, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 106 residents residing in the facility. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella and the facility's water system - Describe the building's water system using text and an accurate flow diagram of the system - Include an assessment of the facility's water system to identify all… […]

• Immediate jeopardy, patternF600Sep 30, 2025

  Based on observation, interview, and record review the facility failed to ensure residents were free from verbal, physical, and sexual abuse between residents residing on the facility's dementia unit. This deficient practice had the potential to affect all 30 residents residing on the facility's dementia unit.12 different allegations/incident of resident to resident abuse were identified during the survey. Facility records indicate R89 has a history of inappropriate sexual behavior. Additionally, a care plan indicated R89 has behavior problems of yelling, grabbing, displaying loving affection towards females, refusing cares, and combative. The facility had an awareness of R89's likelihood to engage in sexually inappropriate behavior and did not take steps to prevent it from occurring. […]

• Immediate jeopardy, patternF610Sep 30, 2025

  Based on interview and record review, the 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. This has the potential to affect all 30 residents on the dementia unit. The facility did not ensure that residents on the unit were protected while the investigation should have been in progress. R89 has a history at the facility of resident-to-resident incidents including punching residents and yelling and swearing at other residents. In addition, R89 has grabbed arms, kicking and punched and hit staff in the face during cares. Supervision for R89 was only increased at time of incidents but then was not continued to prevent further incidents. […]