Waters Edge Health and Rehab: Abuse Not Reported - WI
That was June 4. It happened again in August. The administrator decided that hadn't happened either.
Waters Edge Health and Rehabilitation Center, a nursing home at 3415 N. Sheridan Road in Kenosha, failed to report at least five abuse allegations and one resident-to-resident altercation to state regulators within required timeframes between June and August 2025, according to a federal inspection report completed September 30. Two of those failures involved the same two residents, and the same conclusion from the administrator each time: witnesses said it didn't happen the way staff first reported it, so there was nothing to submit.
The resident at the center of both sexual abuse allegations, identified in the report as R89, was also the subject of a separate incident in late June, when staff documented that he had been verbally assaultive and physically threatening toward another resident, R39. Staff put it in the electronic medical record. They did not tell the administrator. The Director of Nursing later went into that record and wrote that staff had documented what they perceived rather than what actually happened.
On June 4, the inspection report describes what staff found in specific terms: R89 was on his knees at R110's bedside. R110's bed was in its lowest position. Her brief was off. She was not covered by a sheet or blanket. R89's hand was on her vagina area. Staff reported it to the administrator, identified in the report as NHA-A, immediately.
NHA-A reviewed the camera footage and told inspectors that R89 had not been in the room long enough for anything to happen. The facility assembled a soft file of typed, unsigned statements from staff. The state was not notified within two hours as required. Law enforcement was not called.
The same pattern repeated on August 10. Staff reported that R89 was inappropriately touching R110 under her shirt. NHA-A was told right away. Staff were instructed to place R89 on one-to-one supervision. NHA-A told inspectors that the inappropriate touching did not happen. Again, a soft file of typed, unsigned statements. Again, no report to the state within two hours.
When a surveyor interviewed NHA-A on September 2, the administrator did not dispute that she was responsible for submitting facility-reported incidents to the state. She explained her reasoning directly. With all six allegations, she said, witnesses had indicated the incidents did not happen as initially reported. So there was no need to submit them.
She said she had "erred on the side of caution" and had reported other incidents in the past.
The surveyor told her that once an allegation of abuse is reported, the facility has an obligation to report it to the state immediately, and to notify law enforcement when required. NHA-A offered no further information.
The June 28 incident involving R89 and R39 followed a different path to the same destination. Staff observed what they described as verbal assault and physical threatening and entered it into R89's electronic medical record. They did not report it to NHA-A. The Director of Nursing, identified as DON-B, later documented in the same record that staff had written down their perception rather than what actually happened. The state was not notified within 24 hours.
The inspection report does not describe what staff originally wrote, what DON-B believed they had misperceived, or what the Director of Nursing believed had actually occurred instead.
A fifth and sixth failure involved a separate pair of residents. On August 15, R116 and R69 had a physical altercation. The facility conducted an investigation. The completed investigation was submitted to the state on August 25, ten days after the incident. When the surveyor asked NHA-A about the late submission on September 29, NHA-A said she forgot because she had a family emergency.
Taken together, the inspection report documents a facility where the administrator served as the sole decision-maker on whether an abuse allegation was real enough to report, applied that judgment after reviewing camera footage rather than deferring to the staff who witnessed the incidents in person, and consistently concluded that allegations involving the same resident did not meet the threshold for state notification.
The report does not describe any formal investigation into the June 4 incident beyond the camera review. It does not indicate whether R110 was examined by medical staff after either incident. It does not describe what protective measures, if any, were in place between June 4 and August 10, when the second allegation involving the same two residents occurred. It notes that after the August 10 incident, staff were told to place R89 on one-to-one supervision.
The soft files of typed, unsigned statements appear in the report's description of three separate incidents. The report does not describe who typed them, who collected them, or whether the staff members who witnessed the incidents signed anything at all.
What the report does describe is an administrator who, when asked by a federal surveyor why she had not reported abuse allegations to the state, explained that she had made a judgment about their credibility first. And a Director of Nursing who, when staff documented a threatening incident in a resident's medical record, wrote into that same record that what staff had documented was perception, not fact.
R110 is identified in the report only by number. She appears in two incidents, both involving the same alleged perpetrator, both reported immediately by staff to the administrator, and both resulting in no call to the state. The inspection report does not describe her diagnosis, her ability to communicate, or whether she was aware of what was found during either incident.
The facility had no soft file on the June 4 incident, NHA-A told the surveyor. Then the surveyor noted that the facility did, in fact, have one.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 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.
The administrator decided that hadn't happened either.
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.