Waters Edge Health And Rehabilitation Center

cleaned and the resolution notes on the grievances documented sending housekeeping in to clean the

housekeeper-AA who stated that there should be 1 housekeeper on each unit and residents' room

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.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

get between R106 and R121.

Anon-P stated staff couldn't leave the room so Anon-P texted NHA-A.

jeopardy to resident health or and wanted to move out of the room for a long time. R121 would cough a lot and not cover R121's safety mouth. R106 had been threatening R121. R106 had thrown juice at R121 prior to the altercation and Anon-P stated NHA-A had been told to get R106 out of 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 R106 hitting R121 with the pillow. R121 had indicated R106 had hit R121 over and over with pillow by moving hand back and forth and stating “Bam Bam.” 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 R106 in regard to the incident. R106 stated that R121 wouldn't cover R121's mouth and was coughing all the time and spreading germs. R106 was afraid of getting sick. R106 stated R106 asked the social worker several times to move out of the room but it never happened. R106 stated 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 R106 and R121's room after hearing yelling.

Anon-U got into the room and observed R106 repeatedly hitting R121 with a pillow.

Anon-U stated that R121's glasses were crooked on R121's face and R121's was red.

Anon-U stated R121 was facing the window and R106 was hitting R121 over the head with the pillow. R121 has one arm that is contracted so R121 could not stop R106.

Anon-U and Anon-P could not get R121 out of the room to safety because 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 R121 out of the room to safety.

Anon-U stated that R106 was accusing R121 of taking things and informed Anon-U and Anon-P that R106 kept telling the facility R106 wanted out and was fed up.

On 8/28/25, at 10:25 AM, Surveyor was walking down the hallway, and R106 asked to speak to Surveyor. R106 stated R106 wanted to explain what happened with R121. 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 R106 why R106 barricades R106's door. R106 stated it is to stop R89 from wandering in R106's room and taking R106's belongings. R106 stated if R106 catches R89 in R106's room R106 “feels like killing R89” so barricading the door R106 can hear the chair move when sleeping and then knows when someone is coming into R106's room.

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

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

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

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.

allegation of inappropriate sexual contact was not reported to the State Survey Agency within 2 hours and was not thoroughly investigated. (Cross reference F-F600, F-F607 F-F609, F-F610)*On 4/19/25, R89 was observed punching R122 in the face in which R122 sustained a skin tear to the left cheek.

The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F-F600, F-F607 F-F609, F-F610)*On 6/28/25, R89 was observed verbally abusing and physically threatening R39.

The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F-F600, F-F607 F-F609, F-F610)*On 3/17/25, R106 was observed repeatedly hitting R121 with a pillow.

The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F-F600, F-F607 F-F609, F-F610)*On 4/30/25, R106 was heard to physically threaten R121 by stating R106 wanted to cause bodily harm and cause bleeding.

The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F-F600, F-F607 F-F609, F-F610)*Staff are in fear of retaliation and do not know what to report to administration.The administration's failure to review what happened with R110,R26, R121, R57, R122, and R39, its failure to implement procedures to ensure that vulnerable

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

told surveyor there was no soft file on this incident.

NHA-A.

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

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

NHA-A stated the inappropriate sexual behavior could not have happened as NHA-A watched cameras and 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 R89 and R39 was not reported immediately to NHA-A and was not reported to the State Survey Agency within 24 hours.

Staff documented in R89's electronic medical record(EMR) that R89 was verbally assaultive towards R39 and was physically threatening R39.

Staff did not report it to NHA-A.

Director of Nursing (DON)-B documented in 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 R89 and 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 R89 was inappropriately touching R110 under R110's shirt. NHA-A was immediately informed.

Staff were instructed to place 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, R116 and 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.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

immediately to NHA-A. It was reported that R89 had punched R122 in the face causing a skin tear to

jeopardy to resident health or safety On 8/25/25, at 1:01 PM, Surveyor interviewed Anonymous (Anon)-P in regard to the incident between R89 and R122.

Anon-P stated that R89 thought R122 had called R89 a clown. R89 swung out and

cheek. It was reported that NHA-A stated that NHA-A watched cameras, and it never happened and that R122 bit the inside of R122's lip.

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

Surveyor reviewed R122's EMR and notes that R122 has a completed initial wound assessment dated [DATE] that documents 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 R89 and R122.

Anon-S stated that Anon-S was present the night R89 punched R122.

Anon-S heard the punch.

Anon-S was at the nurse's station and R89 and 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 R89 have a stance like R89 had just hit R122 and R122 was holding 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 R122 had hit R122's self.

Anon-S stated that R122's cheek had to be cleaned and treated.

Anon-S stated that R89 is physically aggressive with other residents.

On 8/27/25, at 3:51 PM, Surveyor interviewed NHA-A about the incident between R89 and R122.

NHA-A stated that R122 bit the inside of R122's cheek and nothing happened because the CNA stated R89 and R122 never connected. NHA-A confirmed there is no facility soft file with s

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

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.

(NP)-K informed Surveyor that R11 is hard to figure out and believes it is all in the approach. NP-K has

services.On 8/25/25, at 1:01 PM, Anon-P stated that R11 is not appropriate for the unit and is very

AM, Surveyor interviewed Social Worker Assistant (SWA)-D in regard to R11. SWA-D stated that SWA-D is not a QIDP. SWA-D stated 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 R11 in the hospital.

Anon-R stated staff have not received training on how to best work with R11.On 8/26/25, at 12:37 PM, Anon-G informed Surveyor that the facility is not fully equipped to handle R11.

Anon-G stated that the residents on the unit are more agitated with R11 on the unit. 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 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 R11 and has not been involved in any staff training.

Psych-C stated that R11 almost should have 1:1 supervision. On 8/27/25, at 11:36 AM, Surveyor interviewed Occupational Therapist (COTA)-H in regard to R11. COTA-H stated that COTA-H was not asked to be a part of developing a specialized care plan for R11. On 8/27/25, at 12:27 PM, Medical Director (MD)-J informed Surveyor that MD-J knew R11 at another facility where 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 R11. On 9/2/25, at 8:32 AM, SWA-D confirmed that SWA-D was unaware that R11 requires specialized services. On 9/2/25, at 9:24 AM, Dementia Coordinator (DC)-M is not aware that 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 R11. NHA-A realized that 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 R11 requires specialized services. NHA-A stated that SW-E is reviewing specialized services with SWA-D. NHA-A stated that R11 needs a smaller environment.

Surveyor shared the concern that there is no documentation of the facility tracking and trending R11's behaviors.Surveyor notes that R11's EMR contains no documentation that 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 R11 since 9/2/25.

SWA-D informed Surveyor that psychiatric services have not evaluated or treated R11 since re-admission to the facility. SWA-D confirmed R11 has only been seen on 7/28/25.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

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.

carry out activities of daily living receives the necessary services to maintain good nutrition,

reviewed for ADL's (Activity of Daily Living).R60 was not provided assistance to reposition as she requested until Surveyor intervened and asked staff to assist the resident.Findings include:R60 was admitted to the facility on [DATE] and has diagnoses that include chronic kidney disease stage 3, chronic obstructive pulmonary disease, morbid obesity, asthma, dysphagia, anxiety disorder, major depressive disorder, hypertension, gout, gastroesophageal reflux disease and hereditary and idiopathic neuropathy.R60's BIMS (Brief Interview for Mental Status Score) dated 7/28/25 documents a score of 15, indicating no cognitive impairment.R60's admission MDS (Minimum Data Set) dated 8/3/25 documents: Functional Limitation in Range of Motion lower extremity (hip, knee, ankle, foot) - impairment on both sides.Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed - partial/moderate assistance. R60's Admission/readmission/routine Head to Toe Evaluation dated 7/28/25 documents: Fall Risk evaluation - High risk.R60's Physical Therapy Discharge summary dated [DATE] documents: Bed mobility roll left and right = Substantial/maximal assistance.On 9/22/25 at 11:55 AM, Surveyor observed R60 lying in bed on her back, wearing a gown. R60 told Surveyor she wanted to get boosted up in bed, But the aid said she can't help me because she don't want to hurt her back.

Surveyor offered to find someone to assist R60. R60 stated, Yes, but she won't because she don't want to hurt her back.

Surveyor put R60's call light on and within a minute Certified Nursing Assistant (CNA)-FF entered the room and turned off the call light.

Surveyor told CNA-FF that R60 would like to be repositioned and boosted up in bed. R60 stated to CNA-FF Tell her what you tell me, you can't because you don't want to hurt your back. CNA-FF stated, I can't by myself, I have to get someone to help me and left the room. On 9/22/25 at 12:15 PM, Surveyor noted R60 remained in the same position on her back and noted R60 had slid down more near the middle of the bed.

Surveyor asked if anyone had been in to reposition her yet. R60 stated, No. I told you, she won't because she don't want to hurt her back.

Surveyor observed a different CNA in the dining area where 3 residents were seated eating lunch.

Surveyor observed CNA-FF enter another resident's room.On 9/22/25 at 12:25 PM, Surveyor observed no staff had been in R60's room to reposition/boost her up in bed as requested.

Surveyor observed CNA-FF passing lunch trays to resident rooms.

Surveyor reminded CNA-FF that R60 had asked to be boosted in bed and asked if she has been in her room to reposition her. CNA-FF stated, No, the other aid had to stay in the dining room, so I was alone out here.

Surveyor asked CNA-FF if she asked anyone else for assistance, such as the nurse, to help her reposition R60. CNA-FF stated, No, now I'm passing trays. It had been 30 minutes since Surveyor and R60 requested assistance.On 9/22/25 at 12:33 PM, Surveyor entered R60's room, noting she had not been repositioned or boosted in bed. R60 had received her meal tray.

Surveyor asked R60 if she was having lunch. R60 was tearful and replied (with voice cracking), My back hurts, I need to be boosted. I can't eat now, I'm not hungry, my back hurts. On 9/22/25 at 12:35 PM, Surveyor approached Licensed Practical Nurse (LPN)-Y who was standing at the medication cart at the nurse's station.

Surveyor advised LPN-Y that R60 is uncomfortable, tearful and asked to be repositioned 40 minutes ago.

Surveyor asked LPN-Y if he would help the CNA reposition the resident. LPN-Y stated, Absolutely, I'll go down there right now.

Surveyor observed LPN-Y and another staff member enter R60's room. On 9/22/25 at 1:10 PM, Surveyor observed R60 positioned more upright in bed, with pillows on each side.

When asked how she was feeling, R60 stated, Better, thank you.

Surveyor asked her if now that she was boosted in bed, is she going to have lunch. 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 R60 consumed 75% of her meal, when in fact the resident did not eat lunch.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

to physician orders and the resident?s advance directives.

interview and record review the facility did not ensure its procedures for indicating a residents' code

for 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.R11 was admitted to the facility on [DATE] 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, R11's guardian signed for R11 to be full code status.

Surveyor noted on 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 R11's current physician orders and confirmed R11's full code status is not documented in 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. 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 R11's EMR and LPN-MM confirmed that 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 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 R11's current physician orders to not have an order for 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.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

R131's left leg incision sites.

with tracheostomy, quadriplegia, epilepsy, gastrostomy feeding tube, and metabolic encephalopathy.

R50's admission Minimum Data Set (MDS) assessment dated [DATE] documents R50 is severely cognitively impaired. R50 is dependent for all cares, toileting and mobility. R50 is always incontinent of bowel and bladder.

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 R50 and transferring R50 from R50's bed into R50's Broda chair.

After completing hand hygiene, putting on a gown and gloves, CNA-TT and CNA-SS went to 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. R50 was turned onto left side.

One used brief was removed. CNA-TT completed peri-care and placed the 2 clean briefs under R50. CNA-TT and CNA-SS rolled R50 onto R50's back and completed putting on the 2 clean briefs on R50.

On 9/24/25 at 9:48 AM, Surveyor interviewed CNA-TT.

Surveyor asked how often R50 has R50's brief changed. CNA-TT stated every 2 to 3 hours.

Surveyor asked if it is common to use 2 briefs on R50.

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

Surveyor asked if 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 R50 into double briefs and R50 does not have a care plan intervention to have double briefs.

Surveyor asked if R50 should have been double briefed. DON-B stated only if [R50's power of attorney] wants that.

Surveyor asked where that direction would be documented. DON-B stated in R50's care plan.

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

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

physician order for a right palm guard with carrot to be on every shift.

Both orders were obtained on

In addition, on 8/28/24, a physician order was obtained to check R7's skin integrity with donning (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 R7 was seen for the chief complaint of “ open area to thumb.” Pt (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 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 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 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 (R7) is a total assist of 1 for ADLs and cares.

The patient has severe contractures to both hands an

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

floor.

These occurrences do not have any fall investigations.

pushing through staff in an attempt to get past.

When R11 unable to get through, R11 sat down on the

On 8/2/25, at 11:19 AM, A note written by RN-NN documents “…the patient [R11] would sit on the floor and proceed to drink the soda that R11 had taken… When R11 did stand up with staff help R11 would only take a few short steps before pulling self down again.

This time patient [R11] sat in the other patients doorway .

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

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

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.

trainings for the dementia unit. On 9/2/25, at 12:16 PM, Surveyor interviewed NHA-A in regards to

to have a dementia diagnosis and would benefit from activities. NHA-A stated that residents with

processes, and interventions to take care of the residents on the dementia unit.

Surveyor shared the serious concern with NHA-A that R89 has a diagnosis of dementia and staff have not been trained or have demonstrated the skills to support R89 that are directed towards understanding, preventing, relieving, and/or accommodating R89's distress or loss of abilities.

Surveyor shared that R89's comprehensive care plan has not been assessed, developed, and implemented to meet R89's needs.

Surveyor shared that R89's behavioral expressions may have been exacerbated by environmental triggers in an attempt to communicate an unmet need, discomfort, or thoughts that R89 can no longer verbally communicate.

Surveyor shared the serious concern that the facility based on all of R89's verbal, physical, and sexual incidents did not process a root/cause analysis of R89's expressions in order to provide R89 with the needed specialized services and supports to work with 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 R89.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

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.

400 mg three times daily due to noted increases in expressions.

process is and who is responsible for following up on pharmacy recommendations. DON-B reported

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 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.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

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.

Patient Health Questionnaire (PHQ)-9 score is documented as 14 indicating R11 demonstrates

with resident care, participation in activities, intrudes on privacy or activity of others, disrupts care of living environment. R11's MDS also documents that R11 demonstrates rejection of care and wandering daily. R11's has no range of motion impairment. R11 requires supervision for eating (at time of MDS, R11 was nothing by mouth (NPO), dependent for showers. R11's MDS requires partial/moderate assistance for upper dressing and substantial/maximum for lower body dressing.

R11 is independent for mobility and transfers.

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 R11 would not benefit from skilled therapy services as R11 is currently at baseline with functional mobility. R11 has demonstrated aggressive behaviors, limiting R11's participation and proving unsafe for therapy.

Surveyor notes that therapy disciplines did not attempt to screen 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 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 R11 was readmitted to the facility on [DATE] 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 R11 continues to have, it is concerning that OT and PT have not been involved with new interventions to prevent 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.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

and bed availability is appropriate.* Employee Feedback form initiated to solicit feedback and

jeopardy to resident health or new tool from the Center of Excellence Post-Behavior Root Cause Analysis (RCA) form, providing safety 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

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.

525281 09/30/2025

Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd Kenosha, WI 53140

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.

maintenance director-DD walked around the hallway with a fly swatter and killed flies.

Maintenance

outside that doorway.

Maintenance director-DD stated that there are 2 bug zappers by the main exits,

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.