Waters Edge Health and Rehab: Abuse Unreported - WI
That was April. By the time federal inspectors arrived at Waters Edge Health and Rehabilitation Center on 3415 N. Sheridan Road in September, they had found five separate incidents of resident-on-resident violence or sexual contact that staff had witnessed and administrators had buried.
The resident identified in inspection records as R89 was at the center of two of them. On April 19, R89 punched R122 in the face. The skin tear to R122's left cheek was documented. What wasn't documented in time was the report to the State Survey Agency, which inspectors said should have gone out within 24 hours. It didn't. The investigation that followed, inspectors concluded, wasn't thorough.
R89 appeared again on June 28, this time verbally abusing and physically threatening a different resident, R39. Same result: the state wasn't notified within 24 hours, and the investigation was inadequate.
A second resident, R106, was involved in two additional incidents. On March 17, staff observed R106 repeatedly hitting R121 with a pillow. Six weeks later, on April 30, R106 threatened R121 again, this time verbally, telling R121 that R106 wanted to cause bodily harm and make R121 bleed. Both incidents went unreported to the state within the required window. Neither was thoroughly investigated.
The fifth incident involved an allegation of inappropriate sexual contact. The inspection report does not identify which residents were involved, but it states the allegation was not reported to the State Survey Agency within two hours, as required, and was not thoroughly investigated.
Five incidents. Six residents named in the deficiency summary as having received inadequate administrative review: R110, R26, R121, R57, R122, and R39.
What the inspection report describes inside the facility is an environment where staff had stopped believing they could say anything at all. Inspectors wrote that staff were "in fear of retaliation and do not know what to report to administration." That sentence sits in the middle of a deficiency citation without elaboration, but its weight is considerable. In a building where residents were punching, threatening, and allegedly sexually contacting one another, the people closest to those residents had gone quiet.
The failures inspectors cited ran across multiple federal regulatory tags, including those covering the right to be free from abuse, staff reporting obligations, and the facility's responsibility to investigate and act. The citations were cross-referenced repeatedly, which in inspection language means the same underlying breakdown produced violations in multiple regulatory categories at once.
Waters Edge Health and Rehabilitation Center is a licensed skilled nursing facility. The inspection was completed September 30, 2025. The deficiency statement was printed by the Centers for Medicare and Medicaid Services in August 2026.
None of the inspection findings describe what happened to the residents after the incidents. R122, whose cheek was torn open by a punch in April, is not mentioned again. R121, who was hit with a pillow in March and threatened with bleeding in late April, does not reappear. The report does not say whether R89 or R106 were separated from the residents they had harmed, or whether any protective measures were put in place between incidents.
What it does say is that administration failed to review what happened, failed to implement procedures to protect vulnerable residents, and presided over a staff culture too afraid to report what they saw.
The punch happened in April. The threat to cause bleeding happened ten days later. Inspectors didn't arrive until September.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters Edge Health and Rehabilitation Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 12, 2026 · Our methodology
Waters Edge Health and Rehabilitation Center in KENOSHA, WI was cited for abuse-related violations during a health inspection on September 30, 2025.
By the time federal inspectors arrived at Waters Edge Health and Rehabilitation Center on 3415 N.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.