The Waterview Shores LLC

In the surveyor’s words

From the most serious findings on record at The Waterview Shores LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760May 4, 2026

  Based on interview and record review, the facility failed to ensure that residents were free from a significant medication error for 1 of 3 residents (R1) reviewed for medication errors. The facility's failure to ensure accurate transcriptions and available medication resulted in Immediate Jeopardy for R1 who was administered 39 incorrect and insufficient doses of lactulose (a medication that reduces ammonia levels in the blood) resulting in new onset of seizures, severe hyperammonemia and hospitalization.The IJ began on 4/3/26 when R1 did not receive six doses of scheduled lactulose because the medication was not available. […]

• Actual harm, isolatedF656Sep 11, 2025

  Based on observation, interview, and document review, the facility failed to ensure person centered fall interventions were care planned and implemented for 1 of 3 residents (R1) who were at risk for falls, which resulted in actual harm when R1 sustained a rib fracture as a result of a fall out of bed. The deficient practice was corrected prior to the start of survey, therefore was issued at past noncompliance.Findings include:R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included metabolic encephalopathy (a change in how your brain works due to an underlying condition, can cause confusion or memory loss), neurocognitive disorder with Lewy bodies (a progressive brain disorder), anxiety disorder, and severe cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2025

  Based on observation, interview, and document review, the facility failed to ensure food temperatures were monitored prior to and during meal service to prevent risk of food-borne illness. This had the potential to affect all 42 residents residing at the facility. Findings include: During observation on 6/3/25 at 8:40 a.m., residents were being served breakfast. Breakfast consisted of scrambled eggs, sausage, and cinnamon rolls. Eggs and sausage were in aluminum foil inside of crock pots on both units of the facility. Crock pots were set to the warm setting. Staff served residents individually and plated their requested food from the crock pots. […]

• No harm, potential for more than minimal, widespreadF851Jun 5, 2025

  Based on interview and document review, the facility failed to ensure staffing data was correctly submitted, for 1 of 4 quarters(quarter 3) reviewed, to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings include: The Payroll Based Journal Report (PBJ) [NAME] Report 1705D for quarter 3 2024 (April 1 - June 30), identified the metric for failure to have licensed nursing coverage 24 hours per day and low weekend staffing were triggered. […]

• No harm, potential for more than minimal, widespreadF880Jun 5, 2025

  Based on observation, interview and document review, the facility failed to ensure alcohol-based hand sanitizer was in use in the hand hygiene dispensers throughout the facility. In addition, the facility failed to ensure shared equipment was disinfected between residents for 1 of 2 residents (R9) observed to use a lift; failed to ensure staff completed appropriate hand hygiene and glove use for 2 of 4 residents (R1, R22) observed during cares; failed to ensure the overnight urine collection bag was cleaned prior to storage for 1 of 1 residents (R10) reviewed for catheter care. Findings include: Facility Hand Sanitizer During an observation on 6/3/25 at 3:40 p.m., the hand sanitizer in a free standing black eco lab stand felt like water and did not have an alcohol odor. […]