Waters Edge Health and Rehab: ADL Care Failures - WI
That is what a state surveyor witnessed at Waters Edge Health and Rehabilitation Center on September 22, 2025, according to a federal inspection report.
The resident, identified in inspection records only as R60, was admitted to the facility in late July. Her physical therapy discharge summary documented that she needed substantial to maximal assistance to roll left and right in bed. She had been assessed as a high fall risk. A cognitive evaluation from the same period gave her a perfect score of 15, indicating no impairment. She knew exactly what she needed and she asked for it clearly.
At 11:55 a.m., the surveyor found R60 lying on her back in a hospital gown. R60 said she had asked an aide to boost her up in bed. "But the aid said she can't help me because she don't want to hurt her back," R60 told the surveyor.
The surveyor put on R60's call light. Within a minute, a certified nursing assistant identified in the report as CNA-FF entered, saw the surveyor, and heard the request. R60 told the aide directly: "Tell her what you tell me, you can't because you don't want to hurt your back." The aide said she couldn't do it alone and left to find help.
Nobody came.
By 12:15 p.m., R60 had not been repositioned. She had slid further down toward the middle of the bed. The surveyor noted CNA-FF had gone into another resident's room. A second aide was occupied in the dining area with three residents eating lunch.
By 12:25 p.m., 30 minutes had passed. CNA-FF was now delivering lunch trays to resident rooms. The surveyor stopped her and asked whether she had been back to reposition R60. "No," CNA-FF said. "The other aid had to stay in the dining room, so I was alone out here." The surveyor asked whether she had thought to ask a nurse for help. "No," CNA-FF said. "Now I'm passing trays."
At 12:33 p.m., the surveyor entered R60's room. R60 had not been repositioned. Her lunch tray had arrived. The surveyor asked if she was eating. R60 was in tears, her voice cracking. "My back hurts, I need to be boosted. I can't eat now, I'm not hungry, my back hurts."
The surveyor walked to the nurse's station, where a licensed practical nurse identified as LPN-Y was standing at the medication cart. The surveyor told him R60 was uncomfortable, tearful, and had been waiting 40 minutes. LPN-Y said, "Absolutely, I'll go down there right now." He and another staff member went to R60's room.
By 1:10 p.m., R60 was positioned more upright, with pillows on each side. When the surveyor asked how she was feeling, she said she was better. When asked if she would eat lunch now that she was comfortable, R60 said, "No, I'm not hungry now, just forget it."
Her lunch tray sat untouched.
Someone documented otherwise. The CNA point-of-care record entered at 1:00 p.m. that day listed R60 as having consumed 75 percent of her meal. The inspection report states flatly that the resident did not eat lunch.
The false entry matters beyond paperwork. R60 has dysphagia, a swallowing disorder, in addition to her other diagnoses. Nutrition and intake tracking for a resident with her medical profile is not routine record-keeping. It is clinical data that shapes care decisions.
Waters Edge cited the violation under the federal standard requiring that residents who cannot perform activities of daily living independently receive the necessary assistance to maintain good nutrition, grooming, and personal hygiene, including repositioning. Inspectors rated the harm level as minimal, affecting few residents. The inspection was a complaint survey.
CNA-FF told the surveyor twice that she could not reposition R60 alone, and twice she did not ask for help. The nurse at the medication cart, once told, went immediately. The difference between what happened and what could have happened was one conversation that took 40 minutes and a surveyor's intervention to produce.
R60 said she was better. She still didn't eat.
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 17, 2026 · Our methodology
Waters Edge Health and Rehabilitation Center in KENOSHA, WI was cited for violations during a health inspection on September 30, 2025.
That is what a state surveyor witnessed at Waters Edge Health and Rehabilitation Center on September 22, 2025, according to a federal inspection report.
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.