Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Water's Edge during CMS and state inspections, most recent first.
Food service practices were not followed in a kitchenette when a CNA wore a hair net without fully containing her ponytail, failed to perform hand hygiene after removing gloves and before putting on new gloves, and served drinks while using the same gloves. Staff also did not consistently date an opened milk jug, and a dietary aide used contaminated gloves while touching multiple surfaces and assembling and serving food to a resident.
A resident with moderate cognitive impairment and a care plan supporting meal preferences asked a CNA for tomato soup before the scheduled meal time because the resident was hungry after eating little breakfast. The CNA told the resident lunch was later and said the soup would be brought after attending to another resident, but it was not delivered until lunch time after the resident had been waiting and asking where the food was. The DON stated residents have the right to request food or snacks during all hours of the day, and that condensed soup was available upon request.
Failure to notify the provider of a resident’s weight gains was identified for one resident who was admitted with edema. The resident had repeated overnight weight increases, including gains over the provider’s 3-lb threshold, but no documentation showed that nursing notified the PCP as ordered. An RN and the DON both stated that staff were expected to follow the order and document the communication in the resident’s chart.
A resident with impaired cognition and dependence for toileting, dressing, and hygiene was assisted by two CNAs during morning toileting care. Although the resident and staff noted the resident was very private and had a “bashful bladder,” CNA C remained in the bathroom and continued dressing the resident instead of stepping out to provide privacy. The resident was taken to breakfast without voiding, then later urinated while being lifted onto the toilet, and CNA C acknowledged staff probably should have left the bathroom to allow the resident privacy.
Improper Use of Recliner as a Physical Restraint: A resident with impaired cognition and multiple chronic conditions was observed in a recliner with the footrest elevated while the chair was unplugged from the wall, preventing independent release of the footrest. The care plan stated the recliner was not to be plugged in and could not be used to elevate the legs because that would be a restraint, yet staff were observed and interviewed with inconsistent understanding of how the chair should be used. The resident was also observed yelling for assistance and stating the chair was uncomfortable and wanted to get out to eat lunch.
Two residents were not provided care consistent with their transfer plans. One resident with a history of falls was left unattended on the toilet and was transferred with an EZ Way without the required gait belt or second helper, despite a care plan calling for 2-person assist and no unattended toileting. Another resident with impaired cognition was transferred by CNAs who placed the gait belt high on the chest and lifted under the armpits instead of using the belt at the waist as directed by the care plan and confirmed by the DON.
A resident with type 2 DM and edema had multiple medication administration errors. The MAR showed one instance where BG was 404 and only 4 units of insulin lispro were given instead of the ordered 5 units, and several instances where the resident’s weight increased by 3 lb or more overnight but PRN furosemide was not administered as ordered. An RN and the DON acknowledged the orders and that the PRN medication should have been given when the weight gain threshold was met.
Medication labels for a resident’s torsemide, spironolactone, and gabapentin did not match the physician orders during a med pass. A medication aide was observed using bottles with handwritten changes on the pharmacy labels, while the MAR and physician orders reflected different doses and directions. An LPN and the DON stated that the MAR and bottle label should match.
Failure to perform hand hygiene during resident care was observed when a CNA assisted a resident with toileting, peri care, and dressing without sanitizing hands before donning gloves or between glove changes. The CNA handled the resident’s clothing, body, wheelchair brakes, and handles with contaminated gloves, and later told the surveyor, “Yea, I forgot.” The DON stated the CNA should have sanitized hands prior to applying gloves and in between.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights insufficient environmental safety measures and lack of proper oversight, but does not specify individual residents or staff actions.
The facility failed to maintain an effective infection prevention and control program, as it did not document the time of onset of COVID-19 symptoms for symptomatic staff. This lack of documentation potentially allowed symptomatic employees to work, contributing to a COVID-19 outbreak affecting 12 residents.
Food Handling and Hand Hygiene Deficiencies in Kitchenette
Penalty
Summary
Food service safety practices were not followed in the Sunrise Bay Unit kitchenette when staff prepared and served food to residents. A CNA wore a hair net but did not pull up and cover the ponytail portion of her hair, which hung down to midback, while working in the kitchen and serving food. When asked whether the hair sticking out of the hair net was acceptable, the CNA indicated it was not. Hand hygiene was not performed consistently with glove use during food preparation and service. The CNA washed hands, put on single-use gloves, handled food items and took temperatures with gloved hands, then removed the gloves and did not clean her hands before putting on a new pair. With the new gloves, the CNA handled ice, water, milk, and juice and served drinks to residents in the dining room. The DON stated that hand hygiene is expected before putting on gloves and after removing gloves. Food labeling and glove use practices were also inconsistent. An opened gallon of milk in the kitchenette had no date marked on it, and staff stated they did not usually label milk because it was used the same day. A dietary aide also confirmed there was no opened date on the milk jug and said it was not common practice to mark it. In another observation, a dietary aide serving hot food wore single-use gloves while touching multiple surfaces, including lids, ladles, the steam table edging, plates, bun bags, and a bun, before assembling and serving a cheeseburger and half of a cheeseburger to a resident.
Resident Denied Requested Soup Before Scheduled Meal Time
Penalty
Summary
The facility did not allow a resident’s right to exercise autonomy when choosing a mealtime preference. R10, who had a BIMS score of 11/15 indicating moderate cognitive impairment and made own healthcare decisions, was admitted with a care plan noting mild cognitive impairment and a preference for small lunch portions, with staff to bring lunch and then offer soup and sandwich if the resident chose not to eat it. On 06/29/2026 at 11:00 AM, R10 asked CNA M for a bowl of tomato soup to be delivered to the room because the resident had not eaten much breakfast and was hungry before the scheduled meal time. CNA M told R10 that lunch would be served in 1.5 hours and that the resident could have tomato soup then, and also said the soup would be brought in about 30 minutes after attending to another resident. By 12:08 PM, the soup had not been delivered. At 1:04 PM, R10 was observed in the hallway asking where the food was and stating the resident had been waiting. At 1:05 PM, CNA O delivered a tray of tomato soup and ice cream to the resident’s room. R10 stated the meal finally arrived and reported it had been requested earlier but was not provided until lunch time. The DON stated residents have the right to request food/snacks during all hours of the day, and that condensed soup was available for residents upon request, but also stated soup could be offered at lunch time.
Failure to Notify Provider of Resident Weight Gains
Penalty
Summary
The facility did not notify the provider of changes in condition for 1 of 13 residents reviewed, R7, when the resident’s weight increased and the provider’s order required notification for weight gain greater than 3 lb. R7 was admitted with edema. Review of the MAR showed a weight of 283.6 lb on 03/06/26 and 292 lb on 03/07/26, at which time the provider was notified and an order was entered for 10 mg furosemide and notification of the primary care provider for weight gain greater than 3 lb. Subsequent weight increases were documented on 04/03/26, 04/18/26, 05/12/26, 05/29/26, and 06/24/26, with gains ranging from 3 lb to 7.6 lb overnight, but no notification to the provider was documented for these changes. During interviews on 06/30/26, an RN stated nursing would be expected to notify the provider of changes and document the communication in the resident’s chart, and the DON stated nursing was expected to follow provider orders to notify of changes and document the communication; the DON stated this should have been done for R7’s weight increases.
Failure to Provide Privacy During Toileting Assistance
Penalty
Summary
The facility did not ensure that one resident was provided privacy during personal care. The resident, who had diagnoses including sick sinus syndrome, anemia, hyperlipidemia, seizure disorder, anxiety, and depression, had impaired cognition per the MDS and was dependent on toileting, dressing, and personal hygiene. The resident’s care plan directed staff to assist with toileting on a scheduled bowel and bladder program and noted the resident wore incontinent briefs and needed help adjusting clothes. During morning care, two CNAs assisted the resident to the toilet and remained with the resident while providing care. The resident stated a need to use the bathroom and later indicated a preference for privacy, with staff acknowledging the resident was very private and had a “bashful bladder.” Despite this, CNA C continued dressing the resident in the bathroom and did not step out to provide privacy while the resident remained on the toilet. The resident was then moved out of the bathroom and taken to breakfast without having voided. After breakfast, staff returned the resident to the room and again assisted the resident to the toilet with two aides present. As the resident was being lifted to the toilet, the resident stated, “Oh no, I am peeing right now,” and then continued to urinate. CNA C later acknowledged the resident’s pad was wet and stated staff probably should have stepped out while getting the resident ready for the day so the resident could have urinated in private. The DON stated the expectation was that CNA C should have stepped out of the bathroom so the resident could use the bathroom in private.
Improper Use of Recliner as a Physical Restraint
Penalty
Summary
The facility failed to use the least restrictive device and failed to document ongoing re-evaluation of the need for a physical restraint for one resident, R34, who was placed in a recliner with the footrest elevated and the recliner unplugged from the wall. R34 had diagnoses including diabetes mellitus, spinal stenosis, atrial fibrillation, and chronic kidney disease, and the MDS assessment showed impaired cognition with a BIMS score of 3/15. The resident had no impairment to the upper or lower extremities and required extensive assistance with ADLs, including toileting, transfers, dressing, and personal hygiene. The care plan stated the power recliner was not to be plugged in and could not be used to elevate the legs because that would be a restraint, and OT would provide a footstool for foot elevation. OT documentation noted the chair control was poor and the recliner was unplugged for patient safety. During observation, the resident was seen sleeping in the recliner with the footrest up and the electrical cord unplugged and lying on the floor. On another observation, the resident was sitting in the recliner with feet elevated on the footrest, the recliner unplugged, and the resident yelling out for assistance and stating the chair was uncomfortable and wanted to get out to eat lunch. Staff interviews showed inconsistent understanding of how the recliner was to be used. A CNA stated the recliner stayed unplugged while the resident was in it for safety concerns and that the resident liked to shimmy down toward the end of the footrest to get out of the chair. PT and OT stated residents deemed unsafe to use the recliner remote should be left in the recliner in a sitting position, with feet down, when unplugged. RN and DON also stated the resident should be in a sitting position and never with feet up if the recliner was unplugged. Despite this, the resident was observed in the recliner with the footrest elevated while the chair remained unplugged.
Unsafe transfer techniques and inadequate toileting supervision
Penalty
Summary
The facility did not ensure safe resident handling and supervision during transfers and toileting for two residents. The facility policy titled Safe Resident and Tenant handling, last revised 12/02/2025, states to avoid hazardous resident handling and movement tasks whenever possible and to use resident handling equipment and other approved aids for high-risk tasks. The deficiency involved R6 and R21, both of whom had care plans directing specific transfer assistance and use of gait belts, and both were identified as needing staff assistance with toileting and transfers. R6 was admitted with diagnoses including history of falling, bilateral cataracts, metabolic encephalopathy, and diabetes, and had a BIMS score of 15/15 indicating cognitive intactness. R6's care plan directed two helpers with use of an EZ Way and gait belt for sit-to-stand and chair/bed-to-chair transfers, and stated not to leave R6 unattended in the bathroom because of high fall risk. Surveyors observed CNA M leave R6 unattended on the toilet with the EZ Way device in front of him, then later observed CNA M assist R6 to stand without using a gait belt after R6 questioned the device. CNA M transferred R6 from the bathroom to the wheelchair with the EZ Way without calling for another staff person, despite the care plan directing two-person assistance. R21 was readmitted with diagnoses including fracture of the left humerus, sick sinus syndrome, anemia, hyperlipidemia, seizure disorder, anxiety, and depression, and had impaired cognition with a BIMS score of 5/15. R21's care plan directed two helpers for toilet transfers using a pivot transfer and gait belt. Surveyors observed CNA C and CNA D transfer R21 by lifting under the arms and armpits, placing the gait belt high on the chest under the armpits rather than at the waist, and using the gait belt and underarm lifting during transfers to the wheelchair and toilet. The DON stated the gait belt should be applied at the lower half of the waist and used by holding each side of the belt, not under the armpits.
Medication Orders Not Followed for Insulin and PRN Diuretic
Penalty
Summary
The facility did not ensure that a resident with type 2 diabetes mellitus and edema was free from significant medication errors. The resident had physician orders for insulin lispro by sliding scale four times daily and for furosemide 10 mg PO daily PRN for a weight gain of 3 pounds overnight. Review of the MAR showed one instance in which the resident’s AM blood glucose was 404 and 4 units of insulin lispro were administered, although the order required 5 units. This was identified during survey review of the resident’s medication records. The MAR also showed multiple occasions when the resident’s weight increased by at least 3 pounds overnight and the PRN furosemide was not administered as ordered. These included weight increases from 283.6 lb to 292 lb, 281.6 lb to 284.8 lb, 282.8 lb to 285.8 lb, 290.4 lb to 298 lb, 290.4 lb to 293.6 lb, and 300.2 lb to 303.4 lb. During interview, an RN reviewed the MAR and stated the PRN furosemide had not been given on the dates when the resident’s weight increased 3 pounds and agreed it should have been administered. The DON also acknowledged that nursing staff were expected to follow the provider’s orders and administer the PRN furosemide when the resident’s weight increased by 3 pounds.
Medication Labels Did Not Match Physician Orders
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles for one resident, R20. During a medication pass, a surveyor observed Medication Aide J prepare R20’s medications and noted that the pharmacy labels on torsemide, spironolactone, and gabapentin bottles had handwritten changes made in marker that did not match the physician orders. The torsemide bottle label showed 20 mg with directions for 1 tablet in the morning and 1 tablet in the evening, with the number 1 crossed out and changed to 2, while the MAR reflected torsemide 40 mg, 1 tablet twice daily. The spironolactone bottle label showed 2 tablets daily with the 2 crossed out and changed to 1, and the gabapentin bottle label showed 2 tablets three times daily with the 2 crossed out and changed to 3. Record review showed physician orders for R20 that differed from the pharmacy labels, including torsemide 40 mg PO 1 tablet daily, spironolactone 25 mg PO 1 tablet daily, and gabapentin 300 mg PO 3 capsules three times daily. During interview, LPN K stated that when a medication order changes and the pharmacy label does not match, nursing should verify the order, obtain a new label, and update the MAR so the order matches the bottle. The DON also stated that nursing was expected to ensure the MAR matched the label and that this should have been changed.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
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. During observation of care for one resident, a CNA entered the resident’s room, transferred the resident to a wheelchair, and assisted with toileting and dressing. The CNA applied gloves to gather washcloths, clothes, and shoes, and hand hygiene was not observed before donning gloves. The CNA later removed gloves and put on another pair while continuing care, including assisting the resident to stand and providing peri care. After washing the resident’s peri area, the CNA paused briefly and then pulled the resident’s underwear and pants up with contaminated gloves. The CNA did not doff the contaminated gloves before touching the resident’s clothing, assisting the resident back to the wheelchair by touching under the resident’s armpit, and touching the wheelchair brakes and handles. The CNA also continued to handle trash and clothing items with contaminated gloves before removing them and leaving the room. When interviewed, the CNA stated, “Yea, I forgot,” regarding hand hygiene between glove changes. The DON stated the CNA should have sanitized hands prior to applying gloves and in between.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Inadequate Infection Control Documentation
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, which had the potential to affect all 40 residents. Specifically, the facility failed to complete surveillance for the time of onset of symptoms for COVID-19 symptomatic staff. The surveyor reviewed the facility's procedure for handling ill employee calls and found that it included questions about the onset of symptoms, but the actual surveillance logs did not consistently document the time of onset of symptoms for symptomatic staff. This lack of documentation made it difficult to determine if symptomatic employees should have been in work status. The surveyor found that 7 out of 14 employees who had symptoms of COVID-19 did not have the time of onset of symptoms recorded in the surveillance logs. Interviews with the Infection Preventionist and Employee Health revealed that the facility did not keep track of the time of onset of symptoms, and sometimes the symptoms were not specified on the log sheet. This failure in documentation and tracking potentially allowed symptomatic employees to work, thereby increasing the risk of COVID-19 transmission within the facility. The facility had an outbreak of COVID-19 that affected 12 of the 40 residents, highlighting the critical need for accurate and thorough infection control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hayward Health Services | 12.3 mi | ★★★★★ | 15 | 0 |
| Dove Healthcare - Spooner | 35.8 mi | ★★★★★ | 1 | 0 |
| Ashland Health Services | 38.8 mi | ★★★★★ | 1 | 0 |
| Park Manor Ltd | 39.3 mi | ★★★★★ | 3 | 0 |
| Court Manor Health Services | 39.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.