Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Waterview Woods Llc during CMS and state inspections, most recent first.
Lack of Required RN Coverage: The facility failed to ensure an RN was scheduled for at least 8 hours per day, with staffing records showing repeated days with no RN coverage. Interviews confirmed the facility relied on LPNs and phone availability of RNs, while administration acknowledged it knew weekend RN coverage was lacking and had been cited for the same issue in prior years. The facility assessment did not identify the need for 8 hours of RN coverage.
Failure to Follow SAM Requirements: Two residents were involved in failures related to self-administration of medications. One resident with mild cognitive impairment and provider-documented inability to make medical decisions had medications left at bedside without the required provider order, and the resident could not identify the meds or explain their purpose. Another resident with a SAM form stating the resident could not self-administer or keep meds at bedside still had diclofenac gel left on the nightstand without staff present, and the chart lacked orders authorizing bedside storage or self-administration.
Failure to provide a bed hold notice for a resident transferred to the hospital. The resident was cognitively intact with a stroke diagnosis and left sided hemiplegia, and the record showed transfer by EMS and later a call from the resident about transfer to a larger acute care hospital. The chart lacked documentation that a bed hold was discussed or provided, despite the CM and DON stating bed holds are to be discussed and documented and the facility policy requiring written notice to the resident or representative.
The facility failed to update care plans for two residents with changing care needs. One resident with dementia and PTSD had repeated verbal aggression, threats, medication refusal, and an altercation with another resident, but the care plan did not address behaviors until later. Another resident with MRSA and ESBL was on contact precautions, yet the care plan did not identify those precautions even though staff and the DON said it should have reflected them.
A resident with hearing impairment, cognitive issues, and communication needs was repeatedly observed without hearing aids or headphones, and staff did not use the available devices when he could not hear or understand them. The resident’s guardian reported staff were not using the hearing devices, the headphones were often not charged, and the family was not notified when the resident was moved from a wheelchair to a Broda chair; the DON confirmed staff should have ensured the devices were in place and the guardian notified of the change.
Failure to Reposition and Offload for a Resident With Skin Breakdown: A resident with diabetes, morbid obesity, heart failure, and existing pressure ulcers remained in a wheelchair for prolonged periods with both feet dependent while staff performed other tasks but did not offer repositioning, offloading, or foot elevation. The resident said staff only helped when she used her call light, and multiple nurses confirmed they were waiting for her to ask instead of offering position changes every two hours as ordered.
Failure to Follow Fall-Prevention Interventions for a Resident at Risk for Falls: A resident with moderate cognitive impairment and a history of frequent falls had care plan interventions for wheelchair brakes to be locked, auto-locking brakes to be used, and gripper socks to be worn when out of bed. During observation, the resident self-transferred while the wheelchair brakes were unlocked and was wearing regular socks, and a later observation again found the wheelchair brakes unlocked with no auto-locking devices present.
A resident with COPD, emphysema, respiratory failure, esophagitis, and opioid use had repeated pain complaints that were not consistently monitored or documented. Staff delayed relaying the resident’s requests for PRN morphine, did not provide nonpharmacological pain relief when the resident was observed grimacing and sweating, and progress notes failed to record pain or interventions. Interviews showed communication problems among NAs and LPNs, including limited walkie availability and delays in notifying the nurse of the resident’s request for pain medication.
A resident with heart failure, depression, and anxiety had a basket of medicated creams and powders in the room that included multiple expired items and products without active orders. Surveyors observed several tubes with worn-off labels, and an RN confirmed the items had likely been brought in by family. The CP and DON stated medications in a resident room must have current orders and not be expired, and the facility policy required verification and a physician order before use.
A resident with diabetes, morbid obesity, heart failure, and a pressure ulcer was receiving quetiapine for sleep-related delirium. Monthly pharmacist medication reviews identified that the antipsychotic had been ordered for more than 3 months without a documented GDR attempt, but the recommendation to consider a GDR was not addressed in the provider response or the elder care note. The consultant pharmacist stated she did not receive a response to the requests, and the DON could not find evidence that the GDR had been addressed.
A resident with heart failure, depression, and anxiety had Diclofenac Sodium external gel 1% left on the nightstand without a label showing the resident name, directions for use, open date, or expiration date. An RN confirmed the missing label information, and the CP and DON stated bedside medications should be labeled with the required resident and medication details for safe use.
A resident with moderate cognitive impairment, alcohol dependence, and delirium had an oral/dental evaluation showing plaque, broken teeth, possible cavities, and halitosis. The EMR lacked documentation of a dental referral, and staff and the family member stated no dental evaluation had been arranged despite visible broken teeth and suspected cavities.
A resident with dementia, Parkinson’s disease, CHF, and other chronic conditions was given ciprofloxacin for a presumed UTI after staff obtained a UA largely because the daughter reported increased confusion and behaviors. Nursing notes did not clearly document UTI symptoms or the reason for the UA, and staff interviews showed the resident denied urinary symptoms while staff acknowledged she did not meet UTI criteria. The consultant pharmacist and DON both noted that confusion alone was not an appropriate indication, yet the antibiotic was still started without a documented antibiotic review process.
A resident's bathroom was left with a missing ceiling tile and a wet, stained towel covering an opening above the toilet for at least a month, with ongoing water leakage and standing water present. Staff confirmed the issue persisted, and the infection preventionist noted increased infection risk due to the wet environment.
A resident with multiple serious diagnoses was prescribed buprenorphine 1mg (half of a 2mg tablet) sublingually three times daily, but was given a whole 2mg tablet on six occasions. Documentation and interviews with nursing staff and the acting DON confirmed the error, which was inconsistent with physician orders and facility policy requiring adherence to the five rights of medication administration.
A resident with heart failure and cognitive impairment fell during a transfer using a ceiling lift with an incorrect sling, resulting in a head laceration. The nursing assistant, unfamiliar with the resident, used a half sling found in the room, leading to the resident slipping out and falling. The facility lacked documentation on the correct sling type and size, contributing to the incident.
A facility failed to include specific sling type and size in care plans for residents requiring mechanical lift transfers, leading to a fall incident. One resident with heart failure and aortic stenosis fell during a transfer due to improper sling use, resulting in a head injury. Staff interviews revealed inconsistencies in sling use guidance, and care plans lacked necessary details, despite slings being correct per manufacturer guidelines.
A resident with a known shellfish allergy was served shrimp, resulting in an allergic reaction and emergency treatment. The deficiency was due to a communication failure in documenting and relaying food allergies to kitchen staff. The resident's allergy was not included on the meal ticket, and the dietary sheet lacked a designated area for allergies, leading to the oversight.
The facility did not maintain 8 hours of continuous RN coverage daily, as required, during the third quarter of 2024. This deficiency was confirmed by the CMS PBJ Staffing Data Report, which identified specific dates lacking the required RN presence. The administrator acknowledged the absence of RN coverage and its importance for resident safety. The facility's scheduling and RN coverage policies were not provided.
The facility failed to provide a substantive snack after dinner, resulting in a 15-hour gap between meals, potentially affecting all residents. Interviews revealed that snacks were not readily offered, and residents had to request them. A resident with Parkinson's and diabetes confirmed the absence of an evening snack pass, and LPNs corroborated the lack of a snack cart. The facility's policy of not exceeding 14 hours between meals without a substantial snack was not followed.
The facility failed to ensure proper PPE use for a resident with enhanced barrier precautions, leading to inadequate infection control. Nursing assistants did not wear full PPE during care, and the facility did not conduct necessary COVID-19 testing or infection surveillance among staff. Additionally, the facility lacked an annual review of infection control policies and did not provide evidence-based criteria for infection identification to nursing staff.
A resident with dementia and impaired cognition, requiring supervision during meals, was found eating unsupervised in bed, contrary to their care plan. The resident was on a mechanical soft diet due to swallowing difficulties and was at risk for choking and aspiration. Staff interviews revealed a lack of awareness about the incident, and the DON confirmed the expectation for supervision was not met.
A facility failed to assess and obtain informed consent for bed rail use for a resident with a hip fracture requiring moderate assistance. The resident's care plan and medical record lacked necessary assessments and consent forms. Staff interviews confirmed the absence of required documentation, and the facility's bed rail use policy was not provided.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours a day. Review of staffing schedules dated 4/1/25 through 6/30/25 showed no RN coverage on multiple dates in April, May, and June 2025, and review of the condensed employee time detail confirmed the same lack of RN coverage on those dates. The deficiency was identified during survey review of staffing records and affected all 55 residents who resided at the facility. During interviews, an LPN stated there was usually one licensed staff member with two nursing assistants in the building, with another nursing assistant sometimes floating to assist with rounds, and that an RN was always reachable by phone. An LPN care coordinator stated she was working under the DON because she did not hold an RN license, and an RN unit manager stated she worked Monday through Friday but was always available by phone. The assistant administrator and administrator both acknowledged the facility was aware of the lack of RN coverage on weekends, had been cited for the same concern in previous years, and had been unable to secure weekend RN staffing despite prior agency coverage, job postings, and other staffing efforts. The facility assessment dated 7/17/25 identified licensed nurse staffing ratios and several nursing roles, but did not identify a need for RN coverage 8 hours per day.
Failure to Follow Self-Administration of Medication Requirements
Penalty
Summary
The facility failed to follow its self-administration of medication process for two residents. One resident had a quarterly MDS showing mild cognitive impairment, diagnoses including atrial fibrillation and sepsis, and a care plan stating the resident chose to self-administer oral medications left at bedside after nursing setup. However, the resident’s SAM evaluation indicated the resident could not demonstrate knowledge of what the medications were for, could not recognize the medications, and could not verbalize understanding of their purpose or the correct times to take them. The active order summary lacked provider orders allowing self-administration after nursing setup or allowing medications to be kept at bedside. That resident also had a provider progress note stating the resident could not make medical decisions due to cognitive impairment, with discussion of obtaining POA paperwork and activation based on prior cognitive testing and a below-capacity evaluation. Despite this, a plastic medication cup containing five different medications was observed on the bedside table on multiple occasions when no staff were present. During interview, the resident could not identify the medications, state what they were for, list daily medications, or report signs of adverse reactions or when the medications should be taken. An LPN stated the resident had mental and memory concerns, was given afternoon medications after 2:30 p.m. because he did not like taking them in front of staff, and usually took them with dinner, with staff checking back afterward to make sure they were taken. The second resident had a quarterly MDS indicating cognitive intactness and diagnoses including heart failure, depression, and anxiety. The care plan lacked documentation that the resident could self-administer medications or keep them at bedside, and the active order summary lacked provider orders for either. The SAM form stated the resident could not self-administer medications due to cognitive-related diagnoses and a recent UTI. Even so, a tube of diclofenac sodium external gel was observed on the resident’s nightstand on two occasions with no staff present, and an RN confirmed it had been left there. An RN stated the SAM evaluation considered mental capacity, safe medication use, understanding, and identification of medications, and acknowledged that the SAM evaluation for this resident said the resident could not self-administer or keep medications at bedside.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice for 1 resident who was hospitalized. The resident’s MDS identified the resident as cognitively intact with a diagnosis of stroke and left sided hemiplegia. The face sheet showed the resident was admitted to the facility and later discharged to an acute care hospital. Progress notes documented that the resident was transferred to a local hospital by EMS and later called the facility to report being transferred to a larger acute care hospital. The medical record lacked documentation that a bed hold was given or discussed for either transfer. During interviews, the CM stated that when a resident is transferred to the hospital, a bed hold is to be discussed with the resident or representative and documented in the medical record, and the DON stated all residents who are transferred or go on leave are to have a bed hold done and documented. The facility’s Bed-Holds and Returns policy stated that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.
Failure to Update Care Plans for Behaviors and Contact Precautions
Penalty
Summary
The facility failed to revise resident care plans with updated interventions for behaviors and transmission-based precautions for 2 of 2 residents reviewed. One resident had diagnoses including dementia and post-traumatic stress disorder and was identified on the MDS as severely cognitively impaired with verbal behaviors directed toward others. Although the resident’s care plan was initiated on admission, it did not address behaviors until later. Nursing documentation showed repeated behavioral incidents, including verbal abuse toward staff, threatening another resident who shared a bathroom, throwing medication at staff, and using profanity toward staff while receiving care. The resident was also observed striking another resident with his fists during an altercation in the hallway. Staff interviews confirmed the resident had behaviors, including aggression toward women and an earlier altercation with another resident, and multiple staff verified the care plan did not address those behaviors until after the incidents had occurred. For the second resident, the admission MDS identified no cognitive impairment and a diagnosis of MDRO, and the face sheet identified MRSA and ESBL. A provider order placed the resident on contact precautions, and a sign on the resident’s door identified contact precautions were in place. The care plan dated after the order addressed precautions with cares related to wound care and MDRO and included enhanced barrier precautions, but it did not identify that the resident was on contact precautions. The clinical manager and DON both stated the care plan should have reflected the contact precautions because it was used to communicate the resident’s care needs, and the DON confirmed the care plan should have been updated to reflect that status.
Failure to Use Hearing Devices and Notify Family of Change in Condition
Penalty
Summary
The facility failed to ensure R35’s hearing devices were in use and failed to keep the family member updated on changes in condition. R35’s MDS identified diagnoses including moderate hearing difficulty, mild cognitive function, depression, and anxiety, and noted he was rarely/never understood and had memory problems. His care plan identified altered communication, hard of hearing, and the use of hearing aids or a pocket talker, with staff to offer hearing aids every morning. The care plan also identified fall risk interventions and noted he had been assessed and provided a tilt wheelchair to prevent sliding out on 12/11/24. During observations, R35 was seen multiple times without hearing aids or headphones while in the dining area and in bed, and when spoken to he stated, “I can’t hear you.” NA-A acknowledged he did not hear well and said he had headphones that helped, but she did not use them when he could not understand her. NA-B could not find the hearing aids or headphones in his room, and the headphones were later found plugged in to charge. FM-A stated staff were not using the hearing aids, did not know how to use them, and that she had the hearing aids for repair while the headphones were often not charged. FM-A also stated she was not notified when R35 was moved from a wheelchair to a Broda chair. The DON stated staff should ensure the hearing aids or headphones were in place and charged, and that the guardian should have been involved and notified of the change.
Failure to Reposition and Offload for Resident With Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when staff failed to provide timely assistance with repositioning, offloading, and elevating the feet for a resident with existing skin breakdown. The resident had diagnoses including diabetes, morbid obesity, heart failure, and a pressure ulcer, and was cognitively intact. Her care plan directed staff to turn and reposition or remind her to offload every two to three hours and as needed, and her order summary directed staff to encourage supine positioning at night, elevate her feet two to three times daily for 15 to 20 minutes, use ACE wraps, and offload her heels at all times. The resident’s record did not document refusals of care in November. Observation showed the resident remained in her wheelchair for extended periods with both feet dependent, including while in her room, during lunch, while talking on the phone, after returning from bingo, and while waiting for staff assistance. Staff entered the room multiple times for other tasks, including giving insulin, picking up a meal tray, checking an activity plan, answering a call light, and emptying a Foley catheter, but did not offer repositioning, offloading, or elevation of her feet. The resident stated she had been sitting in her wheelchair since early morning and that staff did not offer position changes unless she used her call light. Interviews with nursing staff confirmed they were not offering her position changes every two hours and were waiting for her to ask, and the DON stated staff should have been following the orders as written and offering repositioning for the resident.
Failure to Follow Fall-Prevention Interventions for a Resident at Risk for Falls
Penalty
Summary
The facility failed to implement fall-prevention interventions for one resident, R44, who had moderate cognitive impairment and diagnoses including alcohol dependence and delirium. R44’s care plan identified him as a fall risk related to dementia and safety, with interventions including keeping the wheelchair at bedside with the brakes locked, using auto-locking brakes on the wheelchair, and ensuring gripper socks were worn when out of bed. During observation, R44 self-transferred from the bed to the wheelchair while the wheelchair locks were not locked and he was wearing regular socks with his shoes on the floor. He was unsteady during the transfer, leaned forward to grab the wheelchair, and the wheelchair rolled backwards before he was able to sit down. A later observation found R44 in bed with his wheelchair next to the bed, but the wheelchair brakes were still not locked and there were no auto-locking devices on the wheelchair. During interview, NA-C stated R44 had a history of frequent falls and confirmed the wheelchair brakes were not locked and no auto-locking brakes were present at that time. RN-A stated fall interventions were placed on the care plan so all staff would be aware and follow them, and that maintenance would be notified when auto-locking brakes were needed. The DON stated all staff were expected to follow the resident plan of care and implement all resident fall interventions to keep the resident safe.
Delayed and Inconsistent Pain Management
Penalty
Summary
The facility failed to monitor pain, provide non-pharmacological pain management, and consistently administer as-needed pain medication to a resident who had pain. The resident had diagnoses including COPD, emphysema, acute and chronic respiratory failure with hypercapnia, and esophagitis, and was receiving hospice services. The admission MDS identified the resident as cognitively aware and noted opioid pain medication use. The pain CAA stated the resident denied physical pain but had epigastric discomfort controlled with omeprazole, yet it did not identify the resident’s opioid medication use. The care plan identified an alteration in comfort and directed staff to provide nonmedicinal pain relief, administer pain medication as ordered, document effectiveness, encourage the resident to verbalize discomfort, and monitor for opioid side effects. The resident had physician orders for morphine sulfate oral solution 10 mg/5 ml, 2.5 ml by mouth every 2 hours as needed for pain related to palliative care, and acetaminophen 650 mg, 2 tablets by mouth every 4 hours as needed for mild to moderate pain or fever related to palliative care. The MAR showed multiple PRN administrations of morphine and acetaminophen for pain ratings of 4 and 5, but the entries did not identify the time of effectiveness. Nursing progress notes dated 11/19/25 through 11/20/25 failed to identify the resident’s pain or any pain interventions attempted to control it. The MHM Pain Evaluation noted the resident used morphine 2 to 3 times a day for pain and inflammation and that staff were to continue monitoring for verbal and non-verbal cues of pain and report changes to the physician. During observation, the resident activated the call light and asked for pain medicine, stating it had been requested about 40 minutes earlier and had not yet been given. The resident was observed lying in bed with the head of bed elevated, grimacing, sweating, rubbing the sternum, and describing mid-chest pain like heartburn. The resident stated staff did not like giving the medication and reported difficulty getting pain medicine during the night as well. Nursing assistant and LPN interviews showed delays and inconsistent communication about the request, with staff stating the nurse was busy, that the request had only been relayed minutes earlier, and that nursing assistants often waited to tell a nurse face to face. Staff also stated there were not enough walkies for all staff, some were missing or broken, and staff sometimes just talked to each other. One LPN stated that when the resident asked again too early for morphine, acetaminophen was given instead, and the resident was left without being told the nurse would return. The DON stated she was unaware there were not enough walkies and expected nursing assistants to report pain medication requests immediately.
Expired and Unordered Medicated Creams Found in Resident Room
Penalty
Summary
The facility failed to ensure that all medications in a resident room had active orders and were not expired. The deficiency involved one resident who was cognitively intact and had diagnoses including heart failure, depression, and anxiety. The resident’s quarterly MDS indicated cognitive intactness, and the care plan did not include documentation related to creams at bedside or labeling requirements. The active order summary showed orders for Diclofenac Sodium external gel 1% and Clotrimazole external cream 1%, but no orders for the other medicated creams or lotions found in the room. Surveyors observed a white basket in the resident’s room on the counter next to the bathroom containing several tubes of medicated creams and powders. When the basket was later reviewed with an RN, several tubes had worn-off labels that could not be read, and multiple products were found with expired dates, including Ketoconazole cream, Triamcinolone acetonide cream, Clotrimazole and betamethasone cream, rosac cream, hydrocortisone 2.5% cream, Santyl cream, and Nystatin powder. The RN stated a family member likely brought the items in and that staff should have reviewed them for current orders and expiration dates. The CP and DON both stated that medications in a resident room needed active orders and should not be expired, and the facility policy stated medications brought in by a resident or responsible party would be used only upon written physician order after verification of contents and acceptable packaging.
Pharmacist GDR Recommendation Not Addressed for Quetiapine
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations were addressed for 1 of 5 residents reviewed for unnecessary medications. The resident’s quarterly MDS identified diagnoses including diabetes, morbid obesity, heart failure, and a pressure ulcer, and also noted that she was cognitively intact, received insulin injections seven days a week, and was receiving an antipsychotic medication. Her care plan identified a potential for psychotropic adverse drug reactions related to daily use of psychotropic medication and included pharmacist medication review and medical provider review as interventions. The resident’s order summary showed quetiapine 25 mg, one-half tablet at bedtime for sleep related delirium due to a known physiological condition. Monthly medication reviews dated 9/11/25 and 10/15/25 both recommended a gradual dose reduction because the quetiapine order had been in place for more than 3 months without a recent documented GDR attempt. One review noted that, unless clinically contraindicated, a GDR should be considered; if not, the low dose should be documented as beneficial. There was no documented provider response on one form, and the 11/13/25 elder care visit note did not address the pharmacy recommendation. During interviews, the consultant pharmacist stated she had not received a response to the September or October requests, and the DON stated the GDR had been referred to elder care but the 60-day note did not show that it was addressed.
Unlabeled topical medication left at bedside
Penalty
Summary
The facility failed to correctly label a prescribed Diclofenac Sodium external gel 1% for one resident who was cognitively intact and had diagnoses including heart failure, depression, and anxiety. The resident’s quarterly MDS indicated cognitive intactness, and the care plan did not include documentation related to creams at bedside or labeling requirements. The resident had active orders for Diclofenac Sodium external gel 1% to be applied to the lower back three times a day, and later an additional order to apply it to the shoulder. A tube of Diclofenac Sodium external gel 1% was observed on the resident’s nightstand on two separate occasions, and it had no label showing the resident name, directions for use, open date, or expiration date. An RN confirmed the tube did not have the required label information. The consultant pharmacist and the DON both stated that any medication left at the bedside should have a label identifying the right resident, right dose, right medication, right time, directions for use, and open and expiration dates. The DON stated Diclofenac was a stock medication and was not aware staff could make their own label if pharmacy would not provide one. The facility policy stated that a label would be affixed to the outside of the prescription container and that floor stock medications would be labeled as floor stock or house supply and kept in the original manufacturer’s container.
Failure to Arrange Dental Evaluation for Resident With Broken Teeth
Penalty
Summary
The facility failed to arrange dental services for a resident with broken teeth and possible cavities. The resident’s quarterly MDS indicated moderate cognitive impairment, and diagnoses included alcohol dependence and delirium. An Oral/Dental Evaluation form dated 11/29/24 documented plaque or debris in localized areas between the teeth, broken teeth, possible cavities, and halitosis. The resident’s electronic medical record from 11/29/24 through 11/19/25 lacked documentation that a dental referral was made for evaluation of the broken teeth and possible cavities. During observation on 11/17/25, the resident was seen with two broken teeth on the lower front tooth line and areas of black and brown on various teeth that appeared to possibly be cavities. A family member stated the resident had broken teeth since admission and was not aware of any contact from the facility about a dental evaluation. Staff interviews indicated dental referrals were expected to be initiated when dental concerns were identified, but no staff had reported the resident needed to see a dentist.
Failure to Review Antibiotic Use Before Treating Presumed UTI
Penalty
Summary
The facility failed to establish and use a process for antibiotic review to determine appropriate indications and resistance before treating a resident with ciprofloxacin for a presumed urinary tract infection. The resident had Parkinson’s disease, atrial fibrillation, congestive heart failure, adult failure to thrive, hypertension, dementia, and cognitive impairment, and was noted to have short-term memory deficits and moderately impaired daily decision-making skills. The resident’s record also reflected urinary and bowel incontinence, occasional straight catheterizations, weakness, gait abnormalities, and hospice involvement. The resident’s nursing notes documented confusion, repeated call light use, yelling, and statements such as fearing a “black hole,” believing staff were talking about her, and asking repeated questions. A urinalysis was collected after the daughter requested it because of increased confusion and behaviors, but the nursing documentation did not identify the resident’s symptoms or why the specimen was obtained. The urinalysis showed clear yellow urine, negative glucose, ketones, protein, and nitrites, with a small leukocyte esterase and 30-50 WBCs; the urine culture later grew Proteus mirabilis. The resident stated she had been told she had a UTI but denied burning, urgency, or discomfort, and said her daughter reported attitude changes. Staff interviews showed inconsistent assessment and documentation practices. An LPN stated the resident did not exhibit UTI symptoms and that the UA was obtained because the daughter requested it; the LPN also did not enter a nursing note because she believed the nurse manager would do so. An RN stated she updated hospice and requested the UA verbally but did not complete a condition note, and acknowledged that a family request for a UA was not an appropriate reason. The DON stated the resident did not meet criteria for a UTI and that confusion and behaviors were related to her diagnoses rather than infection, but the facility still relied on the family’s insistence and the hospice provider’s involvement. The consultant pharmacist noted the monthly medication review did not identify irregularities and stated that, from an antibiotic stewardship standpoint, confusion was not an appropriate indication, while the facility’s antibiotic stewardship policy required review of signs and symptoms, history, medications, allergies, and pertinent test results before contacting the provider.
Failure to Maintain Safe and Clean Resident Environment Due to Ongoing Water Leak
Penalty
Summary
A deficiency was identified when a resident's bathroom was observed to have a missing ceiling tile directly above the toilet, with a wet, stained towel draped across the opening and free-standing water present on the toilet. The resident, who had intact cognition and diagnoses including hypertension, hyperlipidemia, and renal insufficiency, reported that the ceiling tile had been missing and the towel in place for at least a month due to a leak from the room above. Staff interviews confirmed that the condition had persisted for at least a month, with ongoing water leakage resulting in soaked toilet paper and the need to discard it during cleaning. The maintenance director indicated that the leak above had been repaired, but the towel remained to monitor for further leakage. The infection preventionist acknowledged that the presence of wet towels and standing water increased the risk of infection and illness. The regional director of operations stated that such a situation would typically require the resident to be moved and the area repaired before reoccupancy. No policy for environmental services water leakage was provided upon request.
Failure to Administer Correct Dose of Buprenorphine
Penalty
Summary
A deficiency occurred when a resident with diagnoses including a pathological fracture, malignant neoplasm of the esophagus, and aftercare for joint replacement did not receive the correct dose of buprenorphine as ordered by the physician. The physician's order specified that the resident should receive 1mg (half of a 2mg tablet) sublingually three times a day. However, documentation and medication card review revealed that on six separate occasions, the resident was administered a whole 2mg tablet instead of the prescribed half tablet. The medication card was bubble packed with 2mg tablets, and nursing staff were responsible for splitting the tablets to achieve the correct dose. Interviews with an LPN and the acting DON confirmed that the medication sign-out sheet documented the administration of whole tablets rather than half tablets, contrary to the physician's order and facility policy. The facility's policy required nursing staff to follow the five rights of medication administration and to triple check these rights during the process. The failure to administer the correct dose and to document it accurately led to a significant medication error for the resident.
Improper Sling Use Leads to Resident Fall
Penalty
Summary
The facility failed to properly assess, care plan, and ensure the correct sling was used during transfers for a resident reviewed for mechanical lift transfers. The resident was transferred using a ceiling lift with a reported toileting sling of unknown size, which did not cover the buttocks. During the transfer, the resident slipped out of the sling, resulting in a fall and a laceration to the back of the head. This incident was identified as an immediate jeopardy situation. The resident involved had a primary diagnosis of chronic combined systolic and diastolic heart failure and nonrheumatic aortic stenosis, with moderate cognitive impairment. The incident occurred when a nursing assistant, unfamiliar with the resident, used a half sling found in the resident's room for the transfer. The resident began to flail during the transfer, causing them to slip out of the sling and fall to the ground, hitting their head. Interviews with staff revealed that there was a lack of documentation regarding the specific type and size of sling to be used for the resident. The nursing assistant was instructed to use the ceiling lift due to the resident's weakness in the evenings, but the correct sling type and size were not verified. The facility did not have a formal sling assessment form, and the specific sling type and size were not documented in the resident's medical record.
Deficiency in Care Plan for Sling Use in Transfers
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for residents requiring mechanical lift transfers, specifically neglecting to identify the type and size of sling needed. This deficiency was observed in three residents who were reviewed for mechanical lift use. One resident, admitted with chronic heart failure and aortic stenosis, experienced a fall during a transfer when the resident's upper body slid through the sling, resulting in a head injury. The incident report noted that the correct sling and size were used, but the care plan did not specify the sling type or size. Another resident, dependent on staff for transfers due to conditions such as chronic gout and coronary artery disease, also had a care plan that failed to specify the sling type or size. Similarly, a third resident with diagnoses of seizures and arthritis, who was also dependent on staff for transfers, had a care plan lacking this critical information. Interviews with staff revealed that there was confusion and inconsistency in the use of slings, with some staff relying on care sheets that did not provide adequate guidance on sling specifications. The Director of Nursing and other staff members acknowledged the absence of a formal sling assessment form and the lack of documentation regarding sling type and size in the care plans. Observations confirmed that while the slings in resident rooms were correct according to manufacturer guidelines, the care plans did not reflect this information, leading to potential safety risks during resident transfers.
Failure to Prevent Shellfish Allergy Exposure
Penalty
Summary
The facility failed to ensure that a resident with a known allergy to shellfish was not served shellfish, resulting in an allergic reaction. The resident, identified as R209, was admitted to the facility with a documented allergy to shellfish, as noted in both the admission note and care plan dated 10/9/24. Despite this, on 10/13/24, R209 was served a meal containing shrimp, leading to an allergic reaction that required emergency treatment. The incident was identified as an immediate jeopardy situation due to the severity of the allergic reaction. Interviews and document reviews revealed that the communication process for food allergies was flawed. The health unit coordinator (HUC) was responsible for entering allergy information into the electronic medical record (EMR) and completing a dietary sheet for the kitchen staff. However, R209's shellfish allergy was not included on his meal ticket prior to the incident. The culinary director (CD) was the only staff member with access to the dietary system to verify and add food allergies, which contributed to the oversight. Staff interviews indicated that food allergies should be listed on meal tickets and in the EMR, but this was not consistently checked by all staff members. The root cause of the deficiency was identified as a dietary sheet lacking a designated area for allergies, which led to the failure to communicate R209's shellfish allergy to the kitchen staff. This oversight resulted in the resident being served shrimp, despite having a history of severe allergic reactions to shellfish. The facility's policies and procedures for documenting and communicating food allergies were insufficient, leading to the incident where R209 experienced an allergic reaction and required emergency medical attention.
Removal Plan
- All residents were audited for current food allergies.
- The new admission form was modified to add an area specifically to address resident food allergies.
- Dietary policy related to meal tickets was reviewed.
- Resident allergy documentation was reviewed.
- Staff were educated on the meal ticket handling policy and what to do with new admissions form.
Failure to Maintain Continuous RN Coverage
Penalty
Summary
The facility failed to maintain 8 hours of continuous registered nurse (RN) coverage daily, as required. This deficiency was identified through the Centers for Medicare and Medicaid Services' (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of 2024, which showed gaps in RN coverage on multiple dates. Specifically, the facility did not have the required RN coverage on 4/6, 4/7, 4/20, 4/21, 4/27, 4/28, 5/19, 5/25, 5/26, 6/1, 6/2, 6/8, 6/9, and 6/22. During an interview, the administrator confirmed the absence of 8 hours of continuous RN coverage on these dates and acknowledged the importance of having an onsite RN for the safety of the residents. The facility's scheduling policy and RN coverage policy were requested but not provided.
Failure to Provide Substantive Evening Snacks
Penalty
Summary
The facility failed to provide a substantive snack after dinner and before bedtime, resulting in a 15-hour gap between the evening and morning meals, which could potentially affect all residents. Interviews and document reviews revealed that the dietary staff were responsible for restocking snacks, but the nursing staff were tasked with distributing them. However, it was found that there was no evening snack cart, and residents had to request snacks, which were not readily offered by the staff. The kitchen closed at 7 p.m., and the unit fridges, which contained sandwiches, were locked at night, making it difficult for residents to access snacks without staff assistance. A resident with intact cognition and diagnoses of Parkinson's disease and type II diabetes mellitus confirmed the absence of an evening snack pass and the need to request snacks. Interviews with LPNs working both day and evening shifts corroborated the lack of a snack cart and the requirement for residents to ask for snacks. The facility's mealtime document specified that there should not be more than 14 hours between meal services unless a substantial bedtime snack is offered, which was not adhered to, leading to the deficiency.
Inadequate PPE Use and Infection Control Measures
Penalty
Summary
The facility failed to ensure proper utilization of personal protective equipment (PPE) for a resident with enhanced barrier precautions (EBP). The resident, who had severely impaired cognition and was post-colostomy, required staff assistance for various care activities. During an observation, two nursing assistants entered the resident's room for repositioning without wearing the full PPE required for EBP, mistakenly believing that full PPE was only necessary for wound care or COVID-19 cases. Interviews with the nursing staff revealed a lack of understanding and adherence to the EBP requirements, despite the facility's expectations for PPE use during high-contact care. Additionally, the facility did not conduct adequate COVID-19 outbreak testing or infection surveillance among staff members. Despite having two current positive COVID-19 cases among residents, the director of nursing (DON) confirmed that no staff testing had been conducted, relying instead on contact tracing and symptom monitoring. The DON admitted to not performing any surveillance of staff for signs or symptoms of illness and acknowledged the absence of a structured approach to infection surveillance. The facility also failed to annually review its infection control policies and procedures, maintain a current list of reportable communicable diseases, and provide evidence-based surveillance criteria to define infections to nursing staff. The DON indicated that the management company was responsible for policy updates, and there was no form or guide for nurses to use McGreer's criteria for infection identification. Interviews with licensed practical nurses revealed a lack of awareness of any specific criteria or tools to define infections before requesting tests.
Failure to Follow Care Plan for Resident with Choking Risk
Penalty
Summary
The facility failed to adhere to provider orders and care plan interventions for a resident with severely impaired cognition and a diagnosis of dementia. The resident required setup and cleanup assistance with meals and was dependent on others for bed mobility and transfers. According to provider orders, the resident was on a mechanical soft diet due to difficulty swallowing and chewing, and the care plan specified that the resident should eat meals with direct supervision and feeding assistance in the dining room. However, on the observed date, the resident was found lying in bed with the head of the bed elevated only about 30 degrees, slouched down, and with a meal tray on an over-the-bed table. The resident had been eating unsupervised, contrary to the care plan, and was at risk for choking and aspiration. Interviews with staff revealed a lack of awareness and recall regarding the resident's unsupervised meal in bed. A nursing assistant who worked the day shift did not remember the resident eating in bed, and another nearby nursing assistant also had no recollection of the incident. A registered nurse confirmed that the resident was at risk for choking and should not have been eating alone in bed. The director of nursing stated that it was not expected for a known choking risk to be eating in bed unsupervised, highlighting a failure in following the care plan and ensuring the resident's safety.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and obtain informed consent prior to the use of bed rails for a resident who was reviewed for bed rail use. The resident, who had intact cognition and a diagnosis of hip fracture, required moderate assistance with rolling and repositioning. The resident's care plan did not include information related to the use of bed rails, and the medical record lacked an assessment for bed rail alternatives, entrapment risk, or informed consent for bed rail use. During an observation, bed rails were noted to be attached to the head of the bed on both sides. Interviews with facility staff revealed that a Bed Mobility Device Evaluation form should have been completed for all residents prior to the placement of bed rails, which includes evaluating the resident's ability to use the rails, interventions utilized before bed rails, and fall and injury risk. However, the registered nurse confirmed that no assessment or consent forms were present in the resident's chart. The director of nursing stated that it was expected for all staff performing assessments to complete a mobility device assessment and obtain consent before placing bed rails, but the facility's bed rail use policy was not provided.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eveleth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Waterview Pines Llc | 3.5 mi | ★★★★★ | 18 | 1 |
| Essentia Health Virginia Care Cent | 4.5 mi | ★★★★★ | 4 | 0 |
| Cornerstone Villa | 11.3 mi | ★★★★★ | 4 | 0 |
| Essentia Health Northern Pines Medical Center | 15 mi | ★★★★★ | 5 | 0 |
| Heritage Manor | 15.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.