The resident, identified as R50 in the inspection report, depends entirely on staff for toileting, mobility and all personal care. R50's care plan specifically calls for extra large disposable briefs changed every two to three hours as needed.
On September 24 at 9:40 AM, inspectors watched certified nursing assistants TT and SS provide morning care to R50. After putting on protective equipment, the assistants went to R50's bed where two clean briefs sat stacked and opened at the foot of the bed.
The assistants turned R50 to the left side, removed one soiled brief, completed cleaning, then placed both clean briefs under the resident. They rolled R50 back and put both briefs on the resident.
Eight minutes later, inspectors questioned CNA-TT about the double-briefing. The assistant said R50's briefs are normally changed every two to three hours, and explained that "sometimes when R50 is moved, R50 will urinate and that is why 2 briefs were placed on R50."
When asked if the briefs were still clean, CNA-TT looked and confirmed they were.
The practice violated facility policy. At 10:04 AM, inspectors interviewed CNA-CCC, who said residents "can only be double briefed if it is part of the CNA Kardex." The assistant added that some residents prefer double-briefing, but "in that case, it would be care planned and the resident's wishes would be followed."
Four minutes later, Registered Nurse LLL told inspectors that residents can be double-briefed "if it is discussed and care planned ahead of time."
Director of Nursing B confirmed the policy during a 1:12 PM interview. Double-briefing is allowed "if that is their choice," she said, and such preferences "would be documented in the resident's care plan."
When inspectors explained they had observed staff double-briefing R50 without any care plan authorization, DON-B said the practice should only occur "if [R50's power of attorney] wants that." She confirmed such direction would be "documented in R50's care plan."
Inspectors reviewed R50's complete care plan and nursing assistant instructions. No intervention directed staff to use double briefs on the resident.
The violation represents a breakdown in basic care coordination for one of the facility's most vulnerable residents. R50 cannot advocate for personal preferences or question care decisions due to severe cognitive impairment.
Waters Edge Health and Rehabilitation Center operates at 3415 N Sheridan Road in Kenosha. The facility received minimal harm citations during the September 30 complaint investigation, affecting few residents.
The double-briefing incident illustrates how unauthorized care modifications can occur even during routine personal care. Staff acknowledged clear policies requiring care plan documentation for such practices, yet proceeded without proper authorization for a resident entirely dependent on their judgment.
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.
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