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Deficiency Records for Waters Edge Health and Rehabilitation Center

A list of the most recent deficiencies for Waters Edge Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Waters Edge Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Assess the resident when there is a significant change in condition Health 2024-08-05 2024-09-05 N
Ensure each resident receives an accurate assessment. Health 2024-08-05 2024-09-05 N
Assist a resident in gaining access to vision and hearing services. Health 2024-08-05 2024-09-05 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2024-08-05 2024-09-05 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-08-05 2024-09-05 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2024-08-05 2024-09-05 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2024-08-05 2024-09-05 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2024-08-05 2024-09-05 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-08-05 2024-09-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-08-05 2024-09-05 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-08-05 2024-09-05 Y
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2024-08-01 2024-09-05 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2024-08-01 2024-09-05 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-08-01 2024-09-05 N
Meet requirements for the use and maintenance of medical gas equipment. Fire Safety 2024-08-01 2024-09-05 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-08-01 2024-09-04 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-08-01 2024-08-29 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2024-08-01 2024-08-27 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-08-01 2024-08-23 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2024-08-01 2024-08-21 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-08-01 2024-08-14 N
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2024-05-20 2024-06-18 Y
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2024-05-20 2024-06-18 Y
Give residents a notice of rights, rules, services and charges. Health 2024-05-20 2024-06-18 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-05-20 2024-06-18 Y
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Health 2024-05-20 2024-06-18 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-05-20 2024-06-18 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-05-20 2024-06-18 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-05-20 2024-06-18 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-05-20 2024-06-18 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-05-20 2024-06-18 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-05-20 2024-06-18 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-05-20 2024-06-18 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-05-20 2024-06-18 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-12-06 2024-01-06 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-12-06 2024-01-06 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2023-12-06 2024-01-06 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-12-06 2024-01-06 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-12-06 2024-01-06 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-10-04 2023-11-03 Y
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-10-04 2023-11-03 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-10-04 2023-11-03 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-05-24 2023-06-23 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-05-24 2023-06-23 N
Ensure medication error rates are not 5 percent or greater. Health 2023-05-24 2023-06-23 N
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. Health 2023-05-24 2023-06-23 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-05-24 2023-06-23 N
Provide and implement an infection prevention and control program. Health 2023-05-24 2023-06-23 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2023-05-24 2023-06-23 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-05-24 2023-06-23 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-05-24 2023-06-23 Y
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2023-05-24 2023-06-23 N
Provide properly protected cooking facilities. Fire Safety 2023-05-24 2023-06-23 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-05-24 2023-06-23 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2023-05-24 2023-06-23 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-05-24 2023-06-23 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2023-05-24 2023-06-23 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-05-24 2023-06-23 N
Have restrictions on the use of portable space heaters. Fire Safety 2023-05-24 2023-06-23 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-05-24 2023-06-23 N
Have proper medical gas storage and administration areas. Fire Safety 2023-05-24 2023-06-23 N
Provide and implement an infection prevention and control program. Health 2023-02-01 2023-05-16 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-01-10 2023-05-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-10 2023-05-16 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-02-01 2023-04-13 Y
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2023-02-01 2023-04-13 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-02-01 2023-04-13 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-02-01 2023-04-13 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2023-02-01 2023-04-13 Y
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. Health 2023-02-01 2023-04-13 Y
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-01-10 2023-04-13 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-01-10 2023-04-13 Y
Respond appropriately to all alleged violations. Health 2023-01-10 2023-04-13 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-10-06 2022-11-01 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-06-10 2022-07-08 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-06-10 2022-07-08 Y
Conduct testing and exercise requirements. Fire Safety 2022-03-04 2022-04-06 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-03-07 2022-04-05 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-03-07 2022-04-04 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-03-07 2022-04-04 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-03-07 2022-04-04 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2022-03-07 2022-04-04 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2022-03-07 2022-04-04 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-03-07 2022-04-04 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-03-07 2022-04-04 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-03-07 2022-04-04 N
Provide appropriate foot care. Health 2022-03-07 2022-04-04 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2022-03-07 2022-04-04 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-03-07 2022-04-04 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-03-07 2022-04-04 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-03-07 2022-04-04 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-03-07 2022-04-04 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-03-07 2022-04-04 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-03-07 2022-04-04 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-03-07 2022-04-04 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-03-07 2022-04-04 N
Provide and implement an infection prevention and control program. Health 2022-03-07 2022-04-04 N
Perform COVID19 testing on residents and staff. Health 2022-03-07 2022-04-04 N
Ensure staff are vaccinated for COVID-19 Health 2022-03-07 2022-04-04 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2022-03-07 2022-04-04 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2022-03-07 2022-04-04 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-03-07 2022-04-04 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2022-03-07 2022-04-04 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2022-03-07 2022-04-04 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2022-03-07 2022-04-04 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2022-03-07 2022-04-04 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-03-07 2022-04-04 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-03-07 2022-04-04 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-03-07 2022-04-04 Y
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2022-03-04 2022-04-04 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-03-04 2022-04-04 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-03-04 2022-04-04 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-03-04 2022-04-04 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-03-04 2022-04-04 N
Meet requirements for the use of electrical equipment. Fire Safety 2022-03-04 2022-04-04 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-03-04 2022-04-04 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-12-14 2022-01-03 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-14 2022-01-03 Y
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2021-12-14 2022-01-03 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2021-12-14 2022-01-03 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2021-12-14 2022-01-03 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-12-14 2022-01-03 Y

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