Deficiency Records for Waters Edge Health and Rehabilitation Center
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-26 | 2021-05-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-26 | 2021-05-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-06 | 2020-03-05 | 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 | 2020-02-06 | 2020-03-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-06 | 2020-03-05 | 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 | 2020-02-06 | 2020-03-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-06 | 2020-03-05 | 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 | 2020-02-06 | 2020-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-06 | 2020-03-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-02-05 | 2020-03-03 | 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 | 2020-02-05 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-05 | 2020-03-03 | N |
