Waters Edge Rehab: Therapy Delay After Falls - WI
That finding emerged from a complaint inspection completed September 30, 2025.
The resident, identified in inspection records only as R11, had been readmitted to the facility after a lengthy hospitalization. R11 has severe cognitive impairment, short and long-term memory deficits, moderate depressive symptoms, and wanders and rejects care daily. R11 also continued to experience falls after returning to the facility.
The speech therapist screened R11 on September 11, the same day the physician order was written, and recommended no treatment. But occupational therapy and physical therapy did not complete their screens until September 22, eleven days after the order. The Rehabilitation Director told the surveyor that screens should be completed within three days of a physician order.
The delay was only part of the problem. The surveyor noted that therapy staff did not physically reassess R11 after the hospitalization. They relied on previous documentation instead. Nobody examined the resident.
When the surveyor raised the concern on September 24 with the Nursing Home Administrator, Director of Nursing, and two regional operations directors, the facility offered no explanation for why the screens were late.
Five days later, on September 29, the Rehabilitation Director still could not say who had ordered the therapy services on September 11. "Typically there should not be a delay," she said. She did not know why there was one.
R11 had no range of motion impairment and was independent for mobility and transfers, meaning physical and occupational therapy involvement was possible. The surveyor specifically flagged that given R11's ongoing falls, the absence of new PT and OT interventions was a concern. No new interventions had been put in place.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 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 finding emerged from a complaint inspection completed September 30, 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.