Waters Edge Health and Rehab: Resident Beating - WI
The roommate, identified in the inspection report as R106, had been asking to be moved for weeks. He had thrown juice at the victim, R121, before the beating. Staff had told the nursing home administrator to get R106 out of R121's room. None of it happened.
When inspectors arrived on August 26, a staff member described running down the hall after hearing yelling and finding R106 hitting R121 over the head with a pillow. R121's glasses were crooked on his face. His hair was everywhere. His face was red. He has one arm that is contracted, meaning he could not lift it to stop the blows. R121 told staff what had happened the only way he could, moving his hand back and forth and saying "Bam Bam."
Two staff members were in the room and could not get R121 out. R106 wouldn't let them leave. One staff member texted for help. A rehabilitation director, no longer employed at the facility, eventually got R121 out.
R106 did not deny what happened. He explained it to the inspector himself, in his own words, more than once.
"It got to the point where I couldn't handle it anymore," R106 told inspectors on August 26. "It had been building up. It was all me, not him. I was hitting him with the pillow. It just reached a point where I couldn't take it anymore. I was so frustrated."
R106's frustration centered on R121's coughing. R106 told inspectors he was afraid of getting sick and had asked the social worker several times to be moved to a different room. It never happened.
Two days later, on August 28, R106 approached an inspector in the hallway and asked to explain himself again. "They wouldn't listen to me and move me out of the room," he said. "I feel like they tricked me into moving onto the unit. Got to the point with too much frustration. I thought about the pillow and started hitting him with it. I lost it. I didn't want to beat up an old man, but I had enough."
During that same conversation, R106 told the inspector he barricades his door at night because another resident, R89, wanders into his room and takes his belongings. He said if he catches R89 in his room he "feels like killing R89." The barricade, he explained, lets him hear the chair scrape when someone tries to enter so he wakes up in time.
The unit manager, interviewed on September 2, said she was unaware of any roommate problems between R106 and R121.
Federal inspectors rated the violation at the highest level of severity: immediate jeopardy to resident health or safety.
R121 could not stop what was happening to him. His arm was contracted. He was facing the window when R106 came at him. When it was over, he described the beating the only way he had left.
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: August 5, 2026 · Our methodology
Waters Edge Health and Rehabilitation Center in KENOSHA, WI was cited for violations during a health inspection on September 30, 2025.
The roommate, identified in the inspection report as R106, had been asking to be moved for weeks.
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.