Water's Edge

Inspectors wroteThe facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect 21 residents (R4, R10, R11, R12, R13, R14, R15, R16, R18, R19, R26, R27, R29, R6, R31, R32, R35, R36, R39, R40, and R41) of 39 residents on the Sunrise Bay Unit of the facility. Staff did not wear hair restraints properly while preparing food in the kitchenette. Staff did not perform hand hygiene with glove use. Staff did not consistently date or label food items when opened. Staff observed touching ready to eat food with contaminated gloves.

Inspectors wroteBased on observation, interview and record review, the facility did not allow the right to exercise autonomy when choosing a mealtime preference for 1 resident (R10) of 13 residents reviewed for self-determination in a sample of 13 residents. The facility did not allow R10 to have a bowl of soup when requested because it was not during a facility scheduled mealtime. This resulted in R10 being denied the right to make choices about aspects of life that are significant to R10 that could lead to psychosocial harm.

Inspectors wroteBased on interview and record review, the facility did not notify the provider of changes for 1 of 13 residents (R7) reviewed out of 13 sampled residents. R7's weight increased and the provider was not notified per provider's order. This is evidenced by:Facility policy titled, 'Change of Condition,' with no date, states: Immediate notification any symptom, sign, behavior or complaint this is: acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. R7 was admitted to the facility on [DATE] with edema. Surveyor reviewed R7's medication administration record (MAR):On 03/06/26, R7's weight was 283.6 lb. On 03/07/26, R7's weight was 292 lb. Provider was notified and new order entered: Weight gain greater than 3 lb. give 10 mg furosemide and notify primary care provider. On 04/03/26, R7's weight increased by 3.2 lb. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R21) of 13 sampled residents was provided privacy during personal cares. *Certified Nurse Assistant (CNA) C did not provide R21 privacy to use the toilet as requested from R21.

Inspectors wroteBased on observation, interview, and record review, the facility did not use the least restrictive device and document on-going re-evaluation of the need for the restraint for 1 (R34) of 13 sampled residents reviewed for restraints. R34 was placed in a recliner chair with the footrest elevated and recliner unplugged from the wall, which R34 could not independently release the footrest to have unrestricted movement.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received adequate assistance devices and supervision to prevent accidents for 2 residents (R6, R21) of 7 residents reviewed for accidents/hazards in a sample of 13 residents. -R6 was assisted from sitting to standing position by Certified Nursing Assistant (CNA) staff without the use of a gait belt device. -R6 was transferred from toilet to wheelchair with a nonmechanical lift assist device by one CNA staff person when R6's care plan directs 2 persons assist when using lift device.-R6 was left unattended on the toilet by staff when R6's care plan indicated to not leave R6 unattended during toileting. -R21 was assisted from a sitting to standing position by CNA staff without the proper use of a gait belt. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents were free of significant medication errors for 1 of 5 residents (R7) reviewed from a sample of 13 residents. R7's sliding scale insulin and as needed (PRN) furosemide were not administered per physician orders having the potential to cause harm. This is evidenced by:Facility policy titled, 'Medication Administration,' with a reviewed date of 12/03/25, states: All medications will be.administered according to physician order and documentation of administration recorded appropriately in the resident's medical record. R7 was admitted to the facility on [DATE] with type 2 diabetes mellitus and edema. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 6 residents (R20) reviewed from a sample of 13 residents. R20's pharmacy labels for toresemide, spironolactone, and gabapentin did not match the physician order. This is evidenced by:Facility policy titled, 'Medication Administration,' with a reviewed date of 12/03/25, states: All medications will be.administered according to physician order and documentation of administration recorded appropriately in the resident's medical record. General: 6. Medication directions on the pharmacy label should correlate with the medication directions on the MAR.On 07/01/26 at 7:35 AM, Surveyor observed Medication Aide (MA) J prepare and administer medications during medication administration task. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff did not perform hand hygiene after removing soiled gloves during care observations. This affected 1 of 6 residents (R) observed for cares. (R21) Certified Nursing Assistant (CNA) C did not perform hand hygiene when changing gloves while performing peri care for R21.

Inspectors wroteBased on record review, observation, and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (R) (R1 and R2) reviewed. The facility did not ensure R2's bed alarm was functioning to alert staff of self-transfer resulting in R2 falling and sustaining an acute fracture involving the left orbital roof, opacified left frontal sinus consistent with fracture involving its lateral wall, and a left nasal fracture. This example is being cited at actual harm. The facility did not ensure that R1 was transferred with assist of 2 and correct sling causing R1 to fall to the floor.

Inspectors wroteBased on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not describe the building water systems using text and flow diagrams. This has the potential to affect all 37 residents in the facility.

Inspectors wroteBased on record review and interview, the facility did not ensure 1 of 1 resident ((R)8) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. R8 expressed he had lost his son in a tragic car accident which at certain times of the year it is very difficult. The facility did not assess R8 for trauma informed care. R8's care plan did not identify potential triggers in attempts to mitigate re-traumatization. Findings Include: On [DATE] at 1:21 PM, Surveyor requested and received the facility policy titled Trauma-Informed Care dated [DATE]. The policy in part read: Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 40 residents (R). The facility did not complete surveillance for the time of onset of symptoms for COVID-19 symptomatic staff.