The Waterview Shores LLC

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dietary staff adhered to food safety practices during meal preparation. This had the potential to affect residents, guests, and staff receiving meals served from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to change all tube feeding supplies every 24-hours for 1 of 1 (R4) resident reviewed for tube feeding.

Inspectors wroteBased 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. The facility failed to ensure the lactulose order was accurately transcribed into R1's medical record resulting in 39 insufficient doses which subsequently resulted in R1's hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and ensure accurate administration of medications for 3 of 4 residents (R1, R3, R4) reviewed for medications.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review the facility failed to promote a dignified dining experience for 6 of 6 residents reviewed (R1, R2, R3, R4, R5, R6) who required assistance to eat and displayed cognitive impairments.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and document review, the facility failed to ensure Section N of the Minimum Data Set (MDS) was accurately coded for 1 of 3 residents (R7) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to secure an oxygen tank in a resident room for 1 of 1 resident (R32) reviewed for accidents.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the water chamber of a bipap machine was emptied and dried between uses for 1 of 3 residents (R143) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were assisted with activities of daily living (ADLs) in a dignified manner for 2 of 2 residents (R2, R3) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident's care plan was implemented appropriately during transfers for 1 of 2 residents (R2) reviewed.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the hot water was at safe temperatures. This failed practiced placed 24 residents who were independent with their mobility at risk for potential burns.

Inspectors wroteBased on observation, interview, and document review, the facility failed to perform a self-administration of medication assessment and obtain provider orders to have medication left in room for 1 of 1 (R20) resident reviewed for self-administration of medication.

Inspectors wroteBased on observation, interview and document review the facility failed to provide privacy during personal cares for 1 of 3 residents (R13) observed during personal cares.

Inspectors wroteBased on interview and document review, the facility failed to ensure ordered laboratory tests were completed and ordered orthostatic blood pressures (measurements of blood pressures from lying to sitting to standing reviewed looking for a drop in blood pressure with position changes) were completed as ordered for 1 of 1 resident (R13) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders for 2 of 4 residents (R11, R187) observed to receive medication. A total of 2 errors out of 32 opportunities were identified resulting in a facility error rate of 6.25 percent.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use practices were maintained for 1 of 4 residents (R13) observed during personal cares.

Inspectors wroteBased on observation and interview, the facility failed to provide a bathroom call light for 1 of 1 resident (R13) reviewed for call lights.

Inspectors wroteBased on interview and document review the facility failed to ensure timely reporting of an allegation of abuse to the state agency (SA) for 1 of 1 residents who alleged abuse in the facility.