The Waterview Woods LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 31, 2024

  Based on observation, interview and document review, the facility failed to properly assess, care plan, and ensure the correct sling was used during transfers for 1 or 1 resident (R1) reviewed for mechanical lift transfers. The resident was transferred using a ceiling lift with a reported toileting sling (a sling which does not cover the buttocks) of unknown size, fell out of the sling during the transfer, and sustained a laceration to the back of head. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency was issued as past non-compliance. […]

• Immediate jeopardy, isolatedF806Oct 24, 2024

  Based on interview and document review, the facility failed to ensure a resident with an allergy to shellfish was not served shellfish for 1 of 1 resident (R209) reviewed for food allergies. The resident was fed a dinner containing shellfish, had an allergic reaction, and was sent to the emergency department (ED) for treatment. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency is issued as past non-compliance. The IJ began on 10/13/24 at 5:15 p.m. when R209 was served, and consumed, shrimp. R209 complained of numbness of the tongue and lips and was sent to the ED for treatment of allergic reaction. […]

• Immediate jeopardy, isolatedF678Jan 21, 2022

  Based on observation, interview and document review, the facility failed to ensure documentation of each resident's advance directive/code status was consistent throughout their records to ensure the code status reflected resident current resuscitation preferences and physician orders. The facility's failure resulted in an immediate jeopardy, risk of serious harm, injury, or impairment for 1 of 25 residents (R21) reviewed for advance directives. The immediate jeopardy began on [DATE], when it was identified R21 had changed her preference from requesting cardiopulmonary resuscitation (CPR) to do not attempt resuscitation (DNR). […]

• Immediate jeopardy, isolatedF600Mar 19, 2021

  Based on interview and document review, the facility failed to ensure residents were free from alleged abuse for 1 of 7 residents (R1) reviewed for abuse. This resulted in an immediate jeopardy (IJ) for R1, who felt he had been sexually abused. The IJ began on 3/12/21, when R1 alleged nursing assistant (NA)-A forcibly removed his clothing during the night, and R1 felt he had been sexually abused. The IJ was identified on 3/18/21, and nurse consultants (NC)-A and NC-B were notified of the IJ at 3:52 p.m. on 3/18/21. […]

• Actual harm, isolatedF686Feb 8, 2024

  Based on observation, interview and document review, the facility failed to notify the provider, monitor, determine root cause and revise interventions to address pressure ulcers for 1 of 2 residents (R21) reviewed who was at risk for pressure ulcer development/deterioration. The facility's failure resulted in harm when R21 developed 2 pressure ulcers, one that deteriated to a stage 3 and another to a stage 4. In addition, R1 had documented redness and skin breakdown to the buttocks area and a right heel wound that both deteriorated to unstageable pressure ulcers. […]