Waters Edge Rehab: Resident Floor Falls Pattern - WI
The pattern started, at least in the inspection record, on July 12, 2025. A licensed practical nurse documented that the resident, identified in inspection records as R11, was difficult to redirect and was "pushing through staff in an attempt to get past." When R11 couldn't get through, the resident sat down on the floor between staff members and tried to scoot past them.
That was July. The floor incidents kept coming through August.
On August 2, a registered nurse documented that R11 sat on the floor and drank a soda the resident had taken from somewhere, then, when staff helped R11 stand, the resident would take only a few short steps before pulling down again. At one point, R11 sat in another resident's doorway. The nurse wrote that when R11 was unsuccessful at getting into the room, "patient will place self on the floor in hopes to sneak past staff and get into the room."
The next evening, August 3, an agency nurse documented the same thing in a single line: R11 had placed themselves on the floor during that shift.
August 4. A licensed practical nurse documented R11 entering other residents' rooms, and when staff tried to redirect, R11 put themselves on the floor again.
Then August 12, twice in the same day. At 5:39 in the morning, a registered nurse documented R11 sitting on the floor near an exit, having placed themselves there purposefully. Thirteen hours later, a different nurse documented R11 going to the floor again after declining offered items, requiring staff assistance to get back up and return to the resident's room.
August 15 brought another documented incident, the note cut off mid-sentence in the inspection record.
Federal inspectors who reviewed these records cited Waters Edge under a deficiency tag related to accident hazards and supervision, noting the level of harm as minimal harm or potential for actual harm, with some residents affected.
What the records don't show is any documented change in approach between incidents. The notes read like entries in a log, not steps in a plan. July 12, floor. August 2, floor. August 3, floor. August 4, floor. August 12, floor, floor. August 15, floor.
R11's behavior was consistent and predictable across multiple shifts, multiple nurses, agency staff and facility staff alike. The resident had a clear pattern: when redirection failed, the floor was the next move. Staff across at least six separate shifts over five weeks documented the same sequence.
The inspection was completed September 30, 2025, following a complaint. Waters Edge Health and Rehabilitation Center sits at 3415 N Sheridan Road in Kenosha.
What the inspection record doesn't capture is what R11 was looking for in those other rooms, or what happened on the nights and mornings when nobody wrote it down.
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 violations during a health inspection on September 30, 2025.
The pattern started, at least in the inspection record, on July 12, 2025.
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.