Waters Edge Health And Rehabilitation Center

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0583 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Keep residents' personal and medical records private and confidential.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

not get cleaned. CNA-Z stated that it has been reported but not sure what has happened.*) On 9/2/2025, Surveyor reviewed the grievances from May 2025 - August 2025 and noted 11 grievances filed regarding cleanliness during that time. The grievances referenced resident room not being cleaned. The investigation concluded that the resident's rooms were not cleaned and the resolution notes on the grievances documented sending housekeeping in to clean the resident's rooms. Surveyor noted that an investigation documented no resident rooms were cleaned on the 2-south unit on 5/24/2025 - 5/26/2025. On 9/26/2025, at 11:30AM, Surveyor interviewed housekeeper-AA who stated that there should be 1 housekeeper on each unit and residents' room should get cleaned daily, but that does not always happen. Housekeeper-AA was not sure why some resident's rooms do not get cleaned, just that at times housekeeper-AA is asked to clean a resident's room on a different unit than the one assigned. Surveyor asked what gets cleaned daily.

Housekeeper-AA replied that the resident's garbage is emptied, sweep the room, wipe down surfaces, and get bedrooms ready for new admissions. Housekeeper-AA stated that resident rooms get a deep clean monthly. Housekeeper stated that if there is anything on the ground such as a body fluid that is more than a quarter cup in size, housekeeping will not clean it up and that it is the facility staff responsibility to clean which facility staff can not always get to it right away if they are busy.On 9/2/2025 at 11:49AM, Surveyor interviewed district manager-BB who stated housekeeping should clean rooms daily that includes disinfecting surfaces, sweeping, mopping, and cleaning bathrooms. District manager-BB stated that resident get basic cleaning daily and will get a deep clean monthly that includes wiping the bed frame, inside the windows in addition to the basic cleaning. Surveyor asked if there have been concerns with rooms not being cleaned. District manager-BB was aware of some concerns so there have been walk throughs and following up to make sure rooms are being cleaned appropriately daily. Surveyor asked to

review the room walk throughs or audits. District manager-BB stated that the walkthroughs were more

observation and there were no sheets filled out or documentation regarding what rooms were looked at.

Surveyor shared concerns residents had regarding bedrooms not being cleaned daily and that garbage were observed being full. On 9/2/2025, at 4:28PM, Surveyor shared concerns with nursing home administrator (NHA)-A and director of nursing (DON)-B of resident concerns that there bedrooms were not being cleaned daily and Surveyor's observation of full garbage's, odors in bedrooms, and stains on resident sheets.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

had been threatening Resident R121. Resident R106 had thrown juice at Resident R121 prior to the altercation and Anon-P stated NHA-A had been told to get Resident R106 out of Resident R121's room.

On 8/26/25, at 9:52 AM, Surveyor interviewed Anon-P again. Anon-P stated that Anon-P and another staff member heard yelling so both went running. Anonymous (Anon)-U made it to the room first and witnessed Resident R106 hitting Resident R121 with the pillow. Resident R121 had indicated Resident R106 had hit Resident R121 over and over with pillow by moving hand back and forth and stating “Bam Bam.” Resident R121's hair was everywhere, and face was red. DON-B came up then and asked questions.

On 8/26/25, at 10:22 AM, Surveyor interviewed Resident R106 in regard to the incident. Resident R106 stated that Resident R121 wouldn't cover Resident R121's mouth and was coughing all the time and spreading germs. Resident R106 was afraid of getting sick. Resident R106 stated Resident R106 asked the social worker several times to move out of the room but it never happened. Resident R106 stated Resident R106 was so frustrated. “It got to the point where I couldn't handle it anymore. 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.”

On 8/26/25, at 3:21 PM, Surveyor interviewed Anonymous (Anon)-U. Anon-U stated that Anon-U responded to Resident R106 and Resident R121's room after hearing yelling. Anon-U got into the room and observed Resident R106 repeatedly hitting Resident R121 with a pillow. Anon-U stated that Resident R121's glasses were crooked on Resident R121's face and Resident R121's was red. Anon-U stated Resident R121 was facing the window and Resident R106 was hitting Resident R121 over the head with

the pillow. Resident R121 has one arm that is contracted so Resident R121 could not stop Resident R106. Anon-U and Anon-P could not get Resident R121 out of the room to safety because Resident R106 wouldn't let them out of the room. Anon-P texted for help. The rehabilitation director who is no longer employed with the facility was able to get Resident R121 out of the room to safety. Anon-U stated that Resident R106 was accusing Resident R121 of taking things and informed Anon-U and Anon-P that Resident R106 kept telling the facility Resident R106 wanted out and was fed up.

On 8/28/25, at 10:25 AM, Surveyor was walking down the hallway, and Resident R106 asked to speak to Surveyor. Resident R106 stated Resident R106 wanted to explain what happened with Resident R121. Resident R106 stated that “they wouldn't listen to me and move me out of the room. 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.” Surveyor asked Resident R106 why Resident R106 barricades Resident R106's door. Resident R106 stated it is to stop Resident R89 from wandering in Resident R106's room and taking Resident R106's belongings. Resident R106 stated if Resident R106 catches Resident R89 in Resident R106's room Resident R106 “feels like killing Resident R89” so barricading the door Resident R106 can hear the chair move when sleeping and then knows when someone is coming into Resident R106's room.

On 9/2/25, at 9:11 AM, Unit Manager (UM)-F is unaware of any roommate problems between Resident R106 and Resident R121.

On 8/26/25, at 9:00 AM, NHA-A informed Surveyor that R

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0602 during a standard health inspection conducted on 2025-09-30.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Protect each resident from the wrongful use of the resident's belongings or money.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0609

NHA-A told surveyor there was no soft file on this incident.

Level of Harm - Minimal harm or potential for actual harm

4) On 6/4/25, an allegation of sexual abuse involving Resident R89 and Resident R110 was reported immediately to NHA-A.

The allegation of sexual abuse was not reported to the State Survey Agency within 2 hours and law enforcement was not notified.

Residents Affected - Some Staff reported immediately to NHA-A that Resident R89 had been found in Resident R110's room on Resident R89's knees at Resident R110's bedside. Resident R110's bed was in the lowest position. Resident R110's brief was off and was not covered with a sheet or blanket. Resident R89's hand was on Resident R110's vagina area.

NHA-A stated the inappropriate sexual behavior could not have happened as NHA-A watched cameras and Resident R89 was not in the room long enough for anything to happen. The facility had a soft file of typed unsigned statements from staff. 5) On 6/28/25, an allegation of verbal abuse and physical threatening involving Resident R89 and Resident R39 was not reported immediately to NHA-A and was not reported to the State Survey Agency within 24 hours.

Staff documented in Resident R89's electronic medical record(EMR) that Resident R89 was verbally assaultive towards Resident R39 and was physically threatening Resident R39. Staff did not report it to NHA-A. Director of Nursing (DON)-B documented in Resident R89's record that staff had documented what was perceived rather than what actually happened. The facility had a soft file of typed unsigned statements from staff. 6) On 8/10/25, an allegation of sexual abuse involving Resident R89 and Resident R110 was reported immediately to NHA-A.

The allegation of sexual abuse was not reported to the State Survey Agency within 2 hours.

Staff reported that Resident R89 was inappropriately touching Resident R110 under Resident R110's shirt. NHA-A was immediately informed. Staff were instructed to place Resident R89 on 1:1 supervision. NHA-A stated that the inappropriate touching did not happen. The facility had a soft file of typed unsigned statements from staff.

On 9/2/25, at 12:16 PM, Surveyor interviewed NHA-A as to why NHA-A did not report the allegations of abuse and resident to resident altercations. NHA-A confirmed that NHA-A is responsible for coordinating and submitting facility reported incidents (FRI) to the State Survey Agency. NHA-A stated that with all 6 allegations that witnesses indicated that the allegations did not happen as initially reported so there was no need to submit to the State Survey Agency. NHA-A indicated NHA-A has “erred on the side of caution” and reported other incidents. Surveyor shared the concern with NHA-A that once the allegation of abuse is reported, the facility has an obligation to report immediately to the State Survey Agency, including notifying law enforcement if required. The facility has provided no further information at

this time. 7) On 8/15/25, Resident R116 and Resident R69 had a resident to resident altercation. The facility conducted an investigation into the incident, but the completed investigation was submitted late to the State Agency on 8/25/25.

On 9/29/25 at 1:23 p.m. Surveyor interviewed NHA-A. Surveyor asked NHA-A why the completed self report investigation was submitted late to the State Agency. NHA-A stated she forgot because she had a family emergency, and it was submitted late.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

On 8/25/25, at 1:01 PM, Surveyor interviewed Anonymous (Anon)-P in regard to the incident between Resident R89 and Resident R122. Anon-P stated that Resident R89 thought Resident R122 had called Resident R89 a clown. Resident R89 swung out and Anon-P heard Resident R122 say “ouch.” Anon-P observed a small cut on the outside of Resident R122's left cheek. It was reported that NHA-A stated that NHA-A watched cameras, and it never happened and that Resident R122 bit

the inside of Resident R122's lip. Anon-P stated Resident R122 had a fresh injury on the outside of Resident R122's left cheek.

Surveyor reviewed Resident R122's EMR and notes that Resident R122 has a completed initial wound assessment dated [DATE REDACTED] that documents Resident R122 has a new skin tear to the face, however, no other details are documented.

On 8/26/25, at 10:42 AM, Surveyor interviewed Anonymous (Anon)-S in regard to the incident between Resident R89 and Resident R122. Anon-S stated that Anon-S was present the night Resident R89 punched Resident R122. Anon-S heard the punch.

Anon-S was at the nurse's station and Resident R89 and Resident R122 were in front of the nurse's station. Anon-S back was turned at the time, but Anon-S heard the punch. Anon-S observed Resident R89 have a stance like Resident R89 had just hit Resident R122 and Resident R122 was holding Resident R122's lip. Anon-S reported it immediately to NHA-A. Anon-S was then informed by NHA-A that NHA-A had watched the cameras and Resident R122 had hit Resident R122's self. Anon-S stated that Resident R122's cheek had to be cleaned and treated. Anon-S stated that Resident R89 is physically aggressive with other residents.

On 8/27/25, at 3:51 PM, Surveyor interviewed NHA-A about the incident between Resident R89 and Resident R122. NHA-A stated that Resident R122 bit the inside of Resident R122's cheek and nothing happened because the CNA stated Resident R89 and Resident R122 never connected. NHA-A confirmed there is no facility soft file with s

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R11's progress notes contains consistent regular documentation of Resident R11's disruptive behaviors. Examples of behaviors: yelling, turning tables over, disrobing, refusing cares, biting, hitting staff, pulling hair, pinching, impulsive, wandering into other rooms. It is documented that Resident R11 is very hard to redirect. Resident R11 is currently

on 1:1 supervision at all times.Surveyor notes that Resident R106 has been the victim of resident-to-resident altercation three different times, and has been the aggressor in three resident-to-resident altercations.On 8/25/25, at 10:54 AM, Surveyor interviewed Anonymous (Anon)-N. Anon-N stated Resident R11 throws things, pulls hair, flips tables, and is very erratic. Anon-N states have to keep other residents safe, have to move residents quickly to safety when Resident R11 melts down. Anon-N describes the unit as very chaotic and Resident R11 can be very loud and disruptive. Anon-N stated the staff have no say in the care or interventions of Resident R11.On 8/25/25, at 11:32 AM, Nurse Practitioner (NP)-K informed Surveyor that Resident R11 is hard to figure out and believes it is all in the approach. NP-K has not been involved with Resident R11's need for specialized services.On 8/25/25, at 12:17 PM, Anon-O does not know anything about specialized services and has not received any training related to specialized services.On 8/25/25, at 1:01 PM, Anon-P stated that Resident R11 is not appropriate for the unit and is very difficult and has not been given any specific interventions to implement for Resident R11.On 8/26/25, at 7:35 AM, Surveyor interviewed Social Worker Assistant (SWA)-D in regard to Resident R11. SWA-D stated that SWA-D is not a QIDP. SWA-D stated Resident R11 needs a smaller environment. On 8/26/25, at 8:10 AM, Anon-R stated that it is currently calmer on the unit with Resident R11 in the hospital. Anon-R stated staff have not received training on how to best work with Resident R11.On 8/26/25, at 12:37 PM, Anon-G informed Surveyor that

the facility is not fully equipped to handle Resident R11. Anon-G stated that the residents on the unit are more agitated with Resident R11 on the unit. Resident R11 constantly grabs at other residents.On 8/26/25, at 1:42 PM, Surveyor interviewed Psych-C. Psych-C stated that Psych-C was unaware that Resident R11 required specialized services until this morning. Psych-C confirmed that Psych-C has not helped with any development of a specialized care plan for Resident R11 and has not been involved in any staff training. Psych-C stated that Resident R11 almost should have 1:1 supervision. On 8/27/25, at 11:36 AM, Surveyor interviewed Occupational Therapist (COTA)-H in regard to Resident R11. COTA-H stated that COTA-H was not asked to be a part of developing a specialized care plan for Resident R11. On 8/27/25, at 12:27 PM, Medical Director (MD)-J informed Surveyor that MD-J knew Resident R11 at another facility where Resident R11 ripped a television off the wall. On 9/2/25, at 8:10 AM, Social Worker (SW)-E stated that SWA-D would be responsible for developing a specialized service care plan for Resident R11. On 9/2/25, at 8:32 AM, SWA-D confirmed that SWA-D was unaware that Resident R11 requires specialized services. On 9/2/25, at 9:24 AM, Dementia Coordinator (DC)-M is not aware that Resident R11 requires specialized services and does not know what specialized services is.On 9/2/25, at 12:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to specialized services for Resident R11. NHA-A realized that Resident R11 requires specialized services after Surveyor brought it to the attention of Psych-C. SWA-D, per NHA-A should have told Psych-C that Resident R11 requires specialized services. NHA-A stated that SW-E is reviewing specialized services with SWA-D. NHA-A stated that Resident R11 needs a smaller environment. Surveyor shared the concern that there is no documentation of the facility tracking and trending Resident R11's behaviors.Surveyor notes that Resident R11's EMR contains no documentation that Resident R11 has been evaluated and reviewed by psychiatric services since 7/28/25.On 9/29/2025, at 12:00 PM, SWA-D informed Surveyor that SWA-D has not had anything to do with specialized services for Resident R11 since 9/2/25. SWA-D informed Surveyor that psychiatric services have not evaluated or treated Resident R11 since re-admission to the facility. SWA-D confirmed Resident R11 has only been seen

on 7/28/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-09-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0677 Level of Harm - Minimal harm or potential for actual harm

stated, Better, thank you. Surveyor asked her if now that she was boosted in bed, is she going to have lunch. Resident R60 stated, No, I'm not hungry now, just forget it. Surveyor noted the CNA Point of Care documentation enter on 9/22/25 at 1:00 p.m. indicated Resident R60 consumed 75% of her meal, when in fact the resident did not eat lunch.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility did not ensure its procedures for indicating a residents' code status was followed for 1 (Resident R11) of 20 residents sampled.Resident R11 did not have a current physician order for Resident R11's code status.Findings Include:The facility's policy and procedure Communication of Code Status revised 4/1/25 documents: .Explanation and Compliance Guidelines:2. When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. 3. The nurse who notates the physician order is responsible for documenting

the directions in all relevant sections of the medical record.4. The designated sections of the medical record are: physician orders obtained per election form and uploaded signed election form.Resident R11 was admitted to

the facility on [DATE REDACTED] and has a legal guardian. On 9/22/2025, at 12:55 PM Surveyor completed a record

review and notes that on 7/7/25, Resident R11's guardian signed for Resident R11 to be full code status. Surveyor noted on Resident R11's current physician orders, there is no order for full code status.On 9/23/2025, at 1:53 PM, Surveyor received a copy of Resident R11's current physician orders and confirmed Resident R11's full code status is not documented

in Resident R11's current physician orders On 9/23/2025, at 1:55 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-MM. LPN-MM stated that the nurses have basic information for each resident on the unit which includes the code status of each resident. Resident R11's code status documents full code. LPN-MM stated that LPN-MM would also double check in the resident's electronic medical record (EMR). Both Surveyor and LPN-MM pulled up Resident R11's EMR and LPN-MM confirmed that Resident R11 does not have a current code status listed.On 9/23/2025, at 10:14 AM, Surveyor interviewed Social Worker Assistant (SWA)-D in regard to code status. SWA-D stated that SWA-D had nothing to do with obtaining code status or maintaining the code status in a resident's EMR. SWA-D will verify in the care conference of what the code status is. Surveyor notes that Resident R11 has not had a care conference.On 9/24/2025, at 2:57 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Director of Operations (RDO)-XX, and Director of Operations (DO)-YY the concern that Resident R11's current physician orders to not have an order for Resident R11's full code status. NHA-A stated the expectation is that there should be a physician order for code status for each Resident.On 9/25/2025, at 8:12 AM, NHA-A informed Surveyor that the facility conducted an audit of every Resident to verify there was a physician order for code status.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Resident R50's admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] documents Resident R50 is severely cognitively impaired. Resident R50 is dependent for all cares, toileting and mobility. Resident R50 is always incontinent of bowel and bladder. Resident R50's bladder incontinence care plan initiated on 6/16/25 documents the following pertinent intervention: Brief use: The resident uses extra large size disposable briefs. Change every 2-3 hours [frequency] and [as needed].

On 9/24/25 at 9:40 AM, Surveyor observed Certified Nursing Assistant (CNA)-TT and CNA-SS providing morning cares to Resident R50 and transferring Resident R50 from Resident R50's bed into Resident R50's Broda chair. After completing hand hygiene, putting on a gown and gloves, CNA-TT and CNA-SS went to Resident R50's bed. Surveyor noted 2 clean briefs sitting at the end of the bed. Surveyor noted the briefs were piled one on top of the other, opened and ready to be used. Resident R50 was turned onto left side. One used brief was removed. CNA-TT completed peri-care and placed the 2 clean briefs under Resident R50. CNA-TT and CNA-SS rolled Resident R50 onto Resident R50's back and completed putting on the 2 clean briefs on Resident R50.

On 9/24/25 at 9:48 AM, Surveyor interviewed CNA-TT. Surveyor asked how often Resident R50 has Resident R50's brief changed. CNA-TT stated every 2 to 3 hours. Surveyor asked if it is common to use 2 briefs on Resident R50.

CNA-TT stated that sometimes when Resident R50 is moved, Resident R50 will urinate and that is why 2 briefs were placed

on Resident R50. Surveyor asked if Resident R50's briefs are still clean. CNA-TT looked and stated yes.

On 9/24/25 at 10:04 AM, Surveyor interviewed CNA-CCC. Surveyor asked if residents can be double briefed. CNA-CCC stated they can only be double briefed if it is part of the CNA Kardex. CNA-CCC stated some residents prefer to be double briefed and, in that case, it would be care planned and the resident's wishes would be followed.

On 9/24/25 at 10:08 AM, Surveyor interviewed Registered Nurse (RN)-LLL. Surveyor asked if resident can be double briefed. RN-LLL stated a resident can be double briefed if it is discussed and care planned ahead of time.

On 9/24/25 at 1:12 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if residents can be double briefed. DON-B stated yes, if that is their choice. Surveyor asked where that information would be documented. DON-B stated it would be documented in the resident's care plan. Surveyor informed DON-B of the concern that Surveyor observed CNA-TT and CNA-SS place Resident R50 into double briefs and Resident R50 does not have a care plan intervention to have double briefs. Surveyor asked if Resident R50 should have been double briefed. DON-B stated only if [Resident R50's power of attorney] wants that. Surveyor asked where that direction would be documented. DON-B stated in Resident R50's care plan.

Surveyor reviewed Resident R50's care plan and Kardex and did not locate an intervention directing staff to double brief Resident R50.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

(placing on) and doffing (taking off) of contracture management device. If skin breakdown is identified, discontinue contracture management device order and initiate therapy referral. Document skin breakdown

in Initial Wound Evaluation and Risk Management. Every 4 hours for left resting hand splint and right palm guard.

The Nurse Practitioner Progress note, dated 3/20/25, indicates Resident R7 was seen for the chief complaint of “ open area to thumb.” Pt (Resident R7) was visited today as he rested in his wheelchair. His father was at bedside and alerted writer that pt had an open area to his thumb. Writer cleansed the area with normal saline, pat dry, apply TAO (triple antibiotic ointment), dry dressing, and placed a rolled towel in his hand for comfort. No s/s (signs/symptoms) of infection. Slight wheeze continues. No acute distress. Nursing denies s/s pain, cough, congestion, fever, chills, malaise, nausea, vomiting, diarrhea, or constipation. Nursing has no concerns at this time. Medical concerns addressed today: Open area to Left thumb: Cleanse with normal saline, pat dry, apply TAO, dry dressing, and rolled towel for comfort. Wound care to follow.

The Surveyor conducted further medical record review and noted that the facility did not comprehensively assess the open area to Resident R7's left thumb after it was addressed by the Nurse Practitioner on 3/20/25. There were no updates to the plan of care and no indication how the open area may have developed. It was also noted that there was no referral to therapy to further assess the use of the contracture management device (resting hand splint). There is no documentation if/when this area healed.

On 6/13/25, the facility conducted a Braden Skin Assessment and noted that Resident R7 is at high risk for pressure ulcer development.

Nursing note dated 6/23/2025 at 2:16 PM stated, SBAR (situation, background, assessment and recommendation) Communication Evaluation Note Text: Situation: Open blister noted to Lt. inner thumb.

Small amount blood bleeding noted no s/s of infection. Integumentary/Skin: New skin impairment Open blister Lt. inner thumb sm. amt. bleeding noted. Nurses observation of the resident: Sm. open blister to inner Lt. thumb sm. amt. bleeding noted. Cleansed with NS ( normal saline) apply foam dressing.

On 6/23/25, skin assessment indicates that Resident R7 has an open blister to the left inner thumb, non-pressure.

Measurements are 1 cm x 2 cm x 0.1 cm.

The Nurse Practitioner Progress Note dated 6/23/2025 at11:00 PM documents; Chief Complaint-Open area to left inner thumb. General: The patient is a [AGE] year-old male with a PMH (past medical history) of respiratory failure who is trachea dependent. The patient (Resident R7) is a total assist of 1 for ADLs and cares. The patient has severe contractures to both hands an

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

1 On 7/12/25, at 2:45 PM, A note written by LPN-FFF documents “…Difficult to redirect, pushing through staff in an attempt to get past. When Resident R11 unable to get through, Resident R11 sat down on the floor between staff and attempt to scoot past…”

On 8/2/25, at 11:19 AM, A note written by RN-NN documents “…the patient [Resident R11] would sit on

the floor and proceed to drink the soda that Resident R11 had taken… When Resident R11 did stand up with staff help Resident R11 would only take a few short steps before pulling self down again. This time patient [Resident R11] sat in the other patients doorway . When Resident R11 is unsuccessful, patient will place self on the floor in hopes to sneak past staff and get into the room…” 3 On 8/3/25, at 7:54 PM, A note written by Agency Nurse-MMM documents “…Resident R11 placed self

on the floor during this shift.”

On 8/4/25, at 8:10 PM, A note written by LPN-HHH documents “Resident R11 entering other resident's rooms, when attempting to redirect, Resident R11 puts self on floor…” 5 On 8/12/25, at 5:39 AM, A note written by RN-III documents “…Resident R11 is currently sitting on the floor near the exit after setting self purposefully on the floor.” 6 On 8/12/25, at 6:35 PM, A note written by LPN-HHH documents “…Resident R11 did not want the items, Resident R11 put self on floor, assisted Resident R11 off of the floor and was able to bring back to Resident R11's room…” 7 On 8/15/25, at 6:16 AM, A note [NAME]

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0744 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated that Anon-N has not seen any visual hallucinations with Resident R89 and wouldn't know what to look for.On 8/27/25, at 12:37 PM, Surveyor interviewed Medical Director (MD)-J. MD-J has been made aware of Resident R89's behaviors and it is hard to determine with dementia. MD-J stated the facility needs to rule out brain injury, complete blood work, MRI, and/or mental health treatment. MD-J stated Resident R89 should have 1:1 supervision 24 hours 7 days a week. On 8/27/25, at 1:34 PM, Surveyor interviewed Dementia Coordinator (DC)-M.

DC-M stated that DC-M is a certified nursing assistant. DC-M has not seen any delusions/hallucinations in

a long time with Resident R89, about 4 months ago. DC-M stated Resident R89 has ‘word salad'. DC-M confirmed that psychological services have not done any trainings specific to the dementia unit. DC-M stated that Resident R89 does a lot of wandering on the unit.On 8/27/25, at 3:51 PM, NHA-A stated that a training had been done at

the end of April on abuse and neglect and how it applies to dementia. NHA-A stated staff have to look at

the root/cause of a behavior. NHA-A stated the goal is for staff to be trained on 2 different dementia trainings every 2 years alternately.On 8/28/25, at 8:48 AM, Anon-Q confirmed that Anon-Q did not receive any training or training materials to assist with interventions for residents on the dementia unit. Anon-Q stated there have been so many altercations on the dementia unit.On 8/28/25, at 10:37 AM, Anon-II stated Anon-II never received trainings for the dementia unit. On 9/2/25, at 12:16 PM, Surveyor interviewed NHA-A

in regards to Resident R89 and all the allegations of abuse. NHA-A stated the criteria for the dementia unit is for a resident to have a dementia diagnosis and would benefit from activities. NHA-A stated that residents with ‘mid' dementia would be appropriate for the unit. NHA-A stated staff should have the ability, thought processes, and interventions to take care of the residents on the dementia unit. Surveyor shared the serious concern with NHA-A that Resident R89 has a diagnosis of dementia and staff have not been trained or have demonstrated the skills to support Resident R89 that are directed towards understanding, preventing, relieving, and/or accommodating Resident R89's distress or loss of abilities. Surveyor shared that Resident R89's comprehensive care plan has not been assessed, developed, and implemented to meet Resident R89's needs. Surveyor shared that Resident R89's behavioral expressions may have been exacerbated by environmental triggers in an attempt to communicate an unmet need, discomfort, or thoughts that Resident R89 can no longer verbally communicate.

Surveyor shared the serious concern that the facility based on all of Resident R89's verbal, physical, and sexual incidents did not process a root/cause analysis of Resident R89's expressions in order to provide Resident R89 with the needed specialized services and supports to work with Resident R89's diagnosis of dementia. Further, the facility has not provided the specialized dementia training to all staff working the dementia unit. Staff have been unable to assess and provide appropriate dementia care to Resident R89.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0745 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide medically-related social services to help each resident achieve the highest possible quality of life.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

level with follow-up for possible drug level check in a few weeks. Seroquel returned to 400 mg three times daily due to noted increases in expressions.

On 9/25/25, at 2:50 PM, Surveyors interviewed Director of Nursing (DON)-B in regard to what the process is and who is responsible for following up on pharmacy recommendations. DON-B reported the pharmacy sends DON-B an email and then DON-B notifies the Nurse Practitioner or Physician.

On 9/29/2025, at 2:44 PM, Surveyor shared with DON-B, Regional Director of Operations (RDO)-XX, and Director of Operations (DO)-YY the concern that Resident R11's pharmacy reports were not being acknowledged by

the physician with the recommendations as well as to discontinue or keep the medication orders the same.

No further information has been provided by the facility at this time.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-09-30.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-30.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Resident R11's admission Minimum Data Set (MDS) completed 7/9/25 documents Resident R11 demonstrates severely impaired cognitive skills for daily decision making and has short and long term memory deficits. Resident R11's Patient Health Questionnaire (PHQ)-9 score is documented as 14 indicating Resident R11 demonstrates moderate depressive symptoms. Resident R11 demonstrates physical behaviors that significantly interferes with resident care, participation in activities, intrudes on privacy or activity of others, disrupts care of living environment. Resident R11's MDS also documents that Resident R11 demonstrates rejection of care and wandering daily. Resident R11's has no range of motion impairment. Resident R11 requires supervision for eating (at time of MDS, Resident R11 was nothing by mouth (NPO), dependent for showers. Resident R11's MDS requires partial/moderate assistance for upper dressing and substantial/maximum for lower body dressing. Resident R11 is independent for mobility and transfers. Resident R11's current physician orders document: PT(physical therapy)/OT (occupational therapy)/ST (speech therapy)/RT (respiratory therapy) to evaluate and treat as indicated with an order date of 9/11/25.

Speech Therapist (ST)-PPP documented a screen was completed on 9/11/25. ST-PPP documents due to severity of disability and recommended nothing by mouth (NPO), no treatment indicated at this time.

An unsigned therapy screen completed 9/22/25 documents Resident R11 would not benefit from skilled therapy services as Resident R11 is currently at baseline with functional mobility. Resident R11 has demonstrated aggressive behaviors, limiting Resident R11's participation and proving unsafe for therapy.

Surveyor notes that therapy disciplines did not attempt to screen Resident R11 again for rehabilitation services and relied only on previous documentation of therapy disciplines.

On 9/24/2025, at 12:48 PM, Surveyor interviewed Rehabilitation Director (Therapy Director)-VV. Therapy Director-VV stated a screen and/or evaluation should be completed within three days of a physician order.

Therapy Director-VV stated the screen should be completed first and then the continued evaluations.

Therapy Director-VV stated that Resident R11 has been at baseline and nursing reports no changes.

On 9/24/2025, at 2:57 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Director of Operations (RDO)-XX, and Director of Operations (DO)-YY the concern that Resident R11 was readmitted to the facility on [DATE REDACTED] and current physician orders document a PT, ST, and OT evaluation was ordered on 9/11/25. A screen was not completed until 9/22/25, 11 days later for OT and PT, and a ST screen was completed on 9/11/25. Surveyor shared that OT, PT, and ST screens were completed based on documentation only and not actually physically re-assessing after re-admission to the facility after

a lengthy hospitalization. Surveyor shared given the number of falls Resident R11 continues to have, it is concerning that OT and PT have not been involved with new interventions to prevent Resident R11 from falling. No further information has been provided by the facility at this time as to why there was a delay in completing therapy screens.

On 9/29/2025, at 10:25 AM, Therapy Director-VV stated that typically there should not be a delay. Therapy Director-VV does not know who ordered therapy services on 9/11/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

did not see. NHA-A stated that staff have gotten terminated because they did not line up with the plan.

NHA-A stated that had NHA-A had the statements from staff, NHA-A would have reported. Surveyor shared

the serious concern that once an allegation of abuse is reported, there is an obligation for the facility to report the allegation of abuse and complete a thorough investigation. NHA-A stated, if people would just tell me the truth. I don't get why people would not be honest. I can't help that staff lie, what can I do when they lie?On 9/2/25, at 3:06 PM, Anon-Q informed Surveyor that Anon-Q had been suspended upon arriving for shift today. Anon-Q asked Social Worker (SW)-E, why, for telling the truth? Anon-Q stated, I did nothing wrong. They always fire people. I feel defeated. You can't report anything. I know I am going to get fired.

Surveyor notes that Anon-Q was crying during the interview.Surveyor notes that six allegations of abuse reported by staff on the dementia unit were not reported and thoroughly investigated. Staff no longer are confident in reporting allegations of abuse and fear retaliation by administration. Staff do not feel trained to adequately provide care and services to the residents on the dementia unit and do not feel supported by administration to provide person-centered interventions.The failure of administration to ensure the building was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident created a situation of Immediate Jeopardy. The facility removed the jeopardy on 10/30/25 when had completed the following:* Residents reviewed for proper placement on Dementia Unit. 2 Residents identified as needing placement with active efforts for discharge to proper community placement.* admission team aware of additional review to be conducted, when possible placement on Dementia Unit, to ensure resident aligns with unit's goals and bed availability is appropriate.* Employee Feedback form initiated to solicit feedback and solutions when staff see an opportunity and desire to remain anonymous or not.* Facility initiated new tool from the Center of Excellence Post-Behavior Root Cause Analysis (RCA) form, providing additional insight to residents when behaviors occur - this tool utilizes a team approach (huddle) to gain knowledge of behaviors/events. Facility Staff completed this tool for those residents with known behaviors on the dementia unit to further care plan any additional interventions that may reduce resident to resident interactions and behaviors.* Regional Human Resources Director onsite and initiated interviews with current staff* Administrator of Sister Facility, Social Services background, provided remote

review of focused Dementia Unit residents to provide additional suggestions and feedback for interventions, and providing on-site support to assist efforts on 9/30/25.* Current Nursing Home Administrator was placed

on administrative leave by Director of Operations* Re-Education by Director of Operations, to Interdisciplinary Team (Dementia Unit focused) immediately to include the following. Use of Post-Behavior Root Cause Analysis (RCA) Form. Re-Education by IDT, to Facility Staff immediately include the following.

Use of Employee Feedback Form. Facility Staff that have not yet received the re-education, and required to complete, will have these items completed prior to their next scheduled shift.* Monitor: Review of Post-Behavior Root Cause (RCA) completion for behaviors completed 5 days a week for 1 week, then 3 days a week for 2 weeks and 1 x week for 3 weeks.* Use of Employee Feedback Form reviewed upon receipt 5 days per week for 1 week, then 3 days a week for 2 weeks then 1 day a week for 3 weeks.* Ad Hoc QAPI Held on 9/29/25 to discuss the above actions taken.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters Edge Health and Rehabilitation Center

3415 N Sheridan Rd Kenosha, WI 53140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-30.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-09-30.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

Federal health inspectors cited WATERS EDGE HEALTH AND REHABILITATION CENTER in KENOSHA, WI for a deficiency under regulatory tag F-F0887 during a standard health inspection conducted on 2025-09-30.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 27 deficiencies cited during this inspection of WATERS EDGE HEALTH AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

flies around. LPN-Y stated that LPN-Y is agency staff so not in the facility often, but whenever LPN-Y does come to the facility there are always flies around. Surveyor observed flies flying around the 1-north nursing station.On 9/2/2025, at 12:23PM, Surveyor interviewed regional maintenance director (RMD)-CC and maintenance director-DD who stated that they were notified about flies couple weeks ago. Maintenance director-DD stated maintenance director-DD walked around the hallway with a fly swatter and killed flies.

Maintenance director-DD stated that the 1-North hallway seems to get it the worst with flies because there is a back door at the end of the unit and when you exit out that door the dumpsters are located right outside that doorway. Maintenance director-DD stated that there are 2 bug zappers by the main exits, 1 located at

the main entrance, and 1 located at that back door by the dumpsters. Maintenance director-DD stated that

the pest control company was not contacted because the flies were no more than what there usually are in

the facility. RMD-CC stated that there really is not anything that can be done about the flies.On 9/2/2025, at 4:28PM, Surveyor shared concerns with nursing home administrator (NHA)-A and director of nursing (DON)-B of surveyor's observations of flies in the building and resident concerns regarding flies in the facility.

Event ID:

Facility ID:

If continuation sheet