Waters Edge Village

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF600Feb 4, 2026

  [NAME] on observation, interview, and record review, the facility failed to protect residents' rights to be free from resident-to-resident physical abuse for 4 of 5 residents reviewed for abuse. (Residents C, D, E and F)Findings include:Resident B's clinical record was reviewed on 2/2/26 at 10:37 a.m. Diagnoses included dementia, hypertension, major depressive disorder, and anxiety. An 11/10/25, admission, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired with fluctuating levels of inattention and disorganized thinking observed during the assessment period. A current resident care plan indicated a 12/25/25 problem of Resident B may have threatened to hit or physically attack other residents. Resident B may also shove. […]

• No harm, potential for more than minimal, patternF610Feb 4, 2026

  Based on interview and record review the facility failed to complete thorough and accurate investigations of resident-to-resident abuse to mitigate risk to other residents for 5 of 5 residents reviewed for abuse. (Resident B, Resident C, Resident D, Resident E, and Resident F.)Findings include:Resident B's clinical record was reviewed on 2/2/26 at 10:37 a.m. Diagnoses included dementia, hypertension, major depressive disorder, and anxiety.A current resident care plan indicated a 12/25/25 problem of Resident B may have threatened to hit or physically attack other residents. Resident B may also shove. Resident B may also have episodes of shoving, hitting, scratching. Review of Resident B's progress notes indicated the following:12/14/25 at 2:00 p.m. […]

• No harm, potential for more than minimal, patternF755Oct 22, 2024

  Based on record review and interview, the facility failed to ensure narcotic medication administration was documented according to policy for 3 of 3 residents (Resident A, E, and F), and that controlled substance reconciliation was complete and accurate according to facility policy for 3 of 3 medication carts, to assure medications were not diverted by a staff member. Findings include: Review of a Facility Reported Incident dated 9/26/24 at 1:20 p.m., indicated Resident A had reported she had not received her scheduled pain medication on 9/25/24 from the night nurse. Following an investigation, LPN 3 was suspended until the investigation could be completed. a. The clinical record review for Resident A was completed on 10/22/24 at 10:38 a.m. […]

• No harm, potential for more than minimal, patternF561Nov 2, 2022

  Based on observation, interview and record review, the facility failed to allow residents food choices and preferences for 4 of 6 residents reviewed. (Resident 29, Resident 42, Resident 47 and Resident 215) Findings include: 1. During an interview on 10/28/22 at 1:46 p.m., Resident 29 indicated he had not received a menu of what the facility planned to serve for any meals. The staff had not asked him to select his meals nor given him any choices regarding breakfast, lunch or supper each day. He preferred to stay in his room in the morning. He received a food tray at each meal, but the items he received on his meal trays each day were not chosen by him. Resident 29's clinical record was reviewed on 10/31/22 at 3:33 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF609Feb 4, 2026

  Based on interview and record review, the facility failed to report allegations involving abuse immediately to the Administrator and to the State Agency (Indiana Department of Health) as required for 2 of 5 residents reviewed for abuse. (Residents D and F)Findings include:Resident B's clinical record was reviewed on 2/2/26 at 10:37 a.m. Diagnoses included dementia, hypertension, major depressive disorder, and anxiety.An 11/10/25, admission, Minimum Data Set (MDS) indicated the resident was severely cognitively impaired with fluctuating levels of inattention and disorganized thinking observed during the assessment period.A current resident care plan indicated a 12/25/25 problem of Resident B may have threatened to hit or physically attack other residents. Resident B may also shove. […]