Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waterview Lodge Llc, Rehabilitation & Healthcare during CMS and state inspections, most recent first.
The facility failed to offer nourishing bedtime snacks to residents when more than 14 hours elapsed between the evening meal and breakfast. Residents reported that snacks were not offered in the evenings, and the Food Service Director confirmed a 15-hour gap between meals without a process to ensure snacks were provided. This resulted in non-compliance with facility policy and USDA guidelines.
The facility failed to offer the updated 2023-2024 COVID-19 vaccine to eligible residents aged 65 and older, despite CDC recommendations and no medical contraindications. The Infection Preventionist was aware of the guidelines but did not offer the vaccine due to other priorities and anticipation of a new vaccine for the next season.
The facility failed to accurately code MDS assessments for several residents, leading to documentation errors. A resident with schizophrenia was not coded for a major injury after a fall, another with a stroke was incorrectly documented as using restraints, a resident with COPD was not coded for their condition and oxygen use, and a hospice patient was not coded for hospice services. These errors highlight deficiencies in assessing and documenting residents' care needs.
A facility failed to ensure proper resident identification during medication administration, leading to significant medication errors for four residents. The policy required two identification methods, such as a photo and verbal confirmation, but observations showed that an LPN administered medications without using any identifiers due to missing photos in the MARs. Interviews revealed reliance on staff for resident identification and a lack of awareness of the policy by the new DON.
A resident's wheelchair was found with a damaged armrest, compromising safety and comfort. Despite staff awareness, the issue was not logged for maintenance, and the resident had to use a sock to cover the damage. The Unit Manager was unaware of the problem until the surveyor's observation.
The facility failed to investigate an incident of physical aggression between two residents, leading to a room change for one of them. Despite the facility's policy requiring immediate investigation, no action was taken. Staff interviews revealed a lack of awareness and follow-up on the incident, resulting in a failure to protect the residents from potential abuse.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their cognitive and physical needs. A resident with Parkinson's Dementia lacked a care plan for cognitive loss, despite severe impairment. Another resident with dementia and anxiety also lacked a cognitive care plan, despite assessments indicating severe impairment. A third resident experienced a fall with injury, but the facility did not update the care plan with new interventions. The MDS Nurse and ADON acknowledged these oversights during the survey.
A resident with paraplegia and neurogenic bladder was found to have an incorrect size suprapubic catheter in place, contrary to the physician's order for a size 18 Fr catheter. The resident, who was cognitively intact, was observed with a size 20 Fr catheter, which was confirmed by the Unit Manager as incorrect, increasing the risk of bladder irritation, infection, and pain.
A resident with COPD was not provided with the correct oxygen flow rate as ordered by the physician. Despite orders to titrate oxygen between 1 to 5 LPM to maintain saturation levels between 90 to 94%, the resident received only 0.5 LPM. The facility staff failed to notify the physician or adjust the oxygen flow rate, and the updated orders were not transcribed correctly into the treatment administration record.
A facility failed to securely store medications according to professional standards, as observed when a surveyor found wound care medications in an unlocked drawer in a resident's room. The resident, who was cognitively intact and had paraplegia and a pressure ulcer, had Santyl ointment improperly stored, contrary to the facility's policy requiring locked storage.
The facility did not ensure all staff wore hair restraints in the kitchen, leading to a potential contamination risk. A staff member was observed without a hair restraint near food preparation areas, despite knowing the requirement. The Food Service Director confirmed the policy that all individuals in the kitchen must wear hair restraints.
The facility failed to implement proper infection control measures for two residents, one with MRSE and another with an indwelling urinary catheter. The Infection Preventionist did not follow CDC guidelines for Contact Precautions for a resident with MRSE, opting instead for Enhanced Barrier Precautions, which did not require gowns and gloves unless performing high-contact care. Additionally, a resident's catheter tubing was observed on the floor, increasing the risk of infection. These deficiencies highlight lapses in infection prevention protocols.
The facility failed to include the resident census in its daily nurse staffing postings, as observed on two consecutive days. The postings, located in the main lobby, contained the facility's name, date, and staffing details for RNs, LPNs, and CNAs, but left the census row blank. The Scheduler responsible for these postings admitted to having access to the required information but had not included the census data.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to offer each resident a nourishing snack at bedtime when more than 14 hours elapsed between the substantial evening meal and breakfast the following day. Specifically, the facility did not provide items from the basic food groups at bedtime when 15 hours elapsed daily between the scheduled evening meal and breakfast. The USDA guidelines indicate that there are five basic food groups, and the facility's policy requires that at least three meals or their equivalent are served daily, with not more than a 14-hour span between the evening meal and breakfast. However, the facility's meal service times showed that the evening meal was served at 5:00 P.M. to 5:10 P.M., and breakfast was served at 8:00 A.M. to 8:10 A.M., resulting in a 15-hour gap. During a Resident Council Meeting, residents reported that snacks were not offered in the evenings for the past year, although they could request a snack from the nurses' station. The Food Service Director confirmed that 15 hours elapsed between the evening meal and breakfast and that there was no process to ensure each resident was offered a nourishing snack at bedtime. This lack of a structured process to offer snacks resulted in the facility's failure to comply with its policy and the USDA guidelines, leading to the deficiency.
Failure to Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to five residents in accordance with national standards of practice, as recommended by the CDC Advisory Committee on Immunization Practices (ACIP). The residents, all aged 65 years or older, were eligible for an additional dose of the updated 2023-2024 COVID-19 vaccine. Despite the absence of medical contraindications and the fact that none of these residents had received the recommended additional dose, the facility did not offer the vaccine to them. This oversight was identified during a review of the residents' clinical records, which showed that their most recent COVID-19 vaccinations were administered several months prior, and no updated doses were offered after the recommended four-month interval. During an interview, the facility's Infection Preventionist (IP) acknowledged awareness of the CDC's recommendation for an additional COVID-19 vaccine dose for older adults. However, the IP admitted that the updated vaccine was not offered to any eligible residents because she was occupied with other tasks and anticipated a new vaccine for the upcoming 2024-2025 season. This inaction resulted in the facility's failure to adhere to the CDC guidelines and ensure that eligible residents received the recommended COVID-19 vaccine updates.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care needs. Resident #74, who was admitted with paranoid schizophrenia, experienced a fall resulting in a bloody mouth and a fractured finger. The MDS Nurse incorrectly coded this fall as a minor injury, not recognizing the fracture as a major injury. Resident #9, with a history of cerebral vascular accident and vascular dementia, was incorrectly documented as using bedrail restraints daily, despite a consent indicating the use of side rails for bed mobility, not as restraints. Resident #49, diagnosed with schizophrenia and chronic obstructive pulmonary disease (COPD), was not accurately coded for COPD and oxygen use in the MDS assessment, an oversight acknowledged by the MDS Nurse. Lastly, Resident #71, admitted for hospice care with end-stage dementia, was not coded for hospice services in the MDS assessments, despite admission orders indicating the need for such care. These inaccuracies in MDS coding reflect a failure to properly assess and document the residents' conditions and care requirements.
Failure to Use Proper Resident Identification During Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice to ensure that significant medication errors did not occur for four residents. Specifically, the facility did not have an appropriate process in place for identifying residents during the medication pass procedure. The facility's policy required the use of two identification methods before administering medication, such as a photo and verbal confirmation of the last name. However, during observations, it was noted that Nurse #2 administered medications to four residents without using any resident identifiers, as the photos were missing from the Medication Administration Records (MARs). Interviews with Nurse #2, the Unit Manager, and the Director of Nursing revealed that the facility staff relied on other staff members to identify residents during medication administration. The Unit Manager confirmed that there were no photos in the MARs for residents on the second-floor unit, which was against the facility's policy. The Director of Nursing, who was new to the role, was unaware of the requirement for two identifiers during medication administration. This lack of adherence to the facility's policy and the absence of proper resident identification methods led to the deficiency.
Failure to Maintain Resident's Wheelchair in Safe Condition
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for Resident #23, who was observed using a wheelchair with a damaged left armrest. The leather on the front portion of the armrest was torn, and the padding was missing, compromising the resident's comfort and safety. The resident, who has diagnoses including depression, anxiety, and osteoarthritis, had tied a sock around the armrest to compensate for the damage, indicating awareness of the issue and a lack of timely intervention by the facility staff. Despite the resident's report that staff were aware of the issue, the maintenance log for October 2024 showed no record of a repair request for the wheelchair. A Certified Nursing Assistant (CNA) confirmed awareness of the damage and stated that a nurse was informed, but the specific nurse was not identified, and the issue was not logged for maintenance. The Unit Manager was unaware of the problem until the surveyor's observation and acknowledged that unit staff should have notified maintenance promptly.
Failure to Investigate Resident-to-Resident Aggression
Penalty
Summary
The facility failed to investigate an incident of physical aggression between two residents, identified as Resident #49 and Resident #54, which was a violation of their policy on resident abuse. Resident #49, who has schizophrenia and COPD, was reported to have been physically aggressive towards Resident #54, who has bipolar disorder. This incident led to Resident #54 being moved to a different room. Despite the facility's policy requiring immediate investigation of such incidents, no investigation was conducted. Interviews with staff revealed a lack of awareness and follow-up on the incident. The Unit Manager was informed of the room change due to aggression, but the Social Worker was not aware of the details and did not investigate further. The Administrator acknowledged knowing about the room change but was unaware of the aggression and admitted that the incident should have been investigated. This lack of action and communication among staff members resulted in a failure to protect the residents from potential abuse and neglect.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their cognitive and physical needs. Resident #72, diagnosed with Parkinson's Dementia, did not have a care plan addressing cognitive loss and dementia, despite the Minimum Data Set (MDS) assessments indicating severe cognitive impairment. The MDS Nurse acknowledged the absence of a care plan, which should have been in place following the triggering of the Care Area Assessment (CAA) for cognitive loss. Resident #64, admitted with dementia and anxiety, also lacked a comprehensive care plan for cognitive loss. The MDS assessments highlighted the resident's severe cognitive impairment and inability to make decisions. Despite the CAA triggering a need for a cognitive loss care plan, the facility did not provide evidence of such a plan being developed or implemented. The MDS Nurse confirmed the absence of a care plan during the survey. Resident #74, with a history of paranoid schizophrenia, experienced a fall resulting in injury. The facility's care plan for falls did not include new interventions following the incident. The Assistant Director of Nurses (ADON) was responsible for updating care plans after serious events but failed to provide evidence of revisions addressing the fall. This oversight left the resident without an updated care plan to prevent future falls.
Incorrect Catheter Size Used for Resident
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for a resident with an indwelling suprapubic catheter. The deficiency involved the incorrect size of the catheter being used for the resident, who was admitted with diagnoses including paraplegia and neurogenic bladder. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15. The physician's orders specified the use of a size 18 Fr 3-way suprapubic urinary catheter, which was to be changed every four weeks. However, during an observation by the surveyor and Unit Manager, it was noted that the resident had a size 20 Fr catheter in place instead of the ordered size 18 Fr. The Unit Manager confirmed that the incorrect size catheter was used, acknowledging that the resident should have had a size 18 Fr catheter as per the physician's order. This oversight placed the resident at increased risk for bladder irritation, infection, and pain.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #49, by not adhering to the physician's orders regarding oxygen administration. The resident, who was admitted with diagnoses including schizophrenia and chronic obstructive pulmonary disease (COPD), required oxygen support to maintain adequate oxygen saturation levels. Despite the physician's orders to titrate oxygen between 1 to 5 liters per minute (LPM) to maintain oxygen saturation levels between 90 to 94%, the resident was observed receiving only 0.5 LPM of oxygen. The facility's policy mandates notifying the physician when there is a change in a resident's condition or when treatment needs to be altered. However, the staff failed to notify the physician or adjust the oxygen flow rate as per the updated orders following the resident's hospitalization and subsequent follow-up with a pulmonologist. The resident's treatment administration record (TAR) for October 2024 showed consistent administration of oxygen at 0.5 LPM, contrary to the physician's orders. During an interview, the Unit Manager acknowledged the oversight, stating that the physician's updated orders were not transcribed correctly into the TAR. This failure to comply with the prescribed oxygen flow rate and to communicate effectively with the physician resulted in the resident not receiving the appropriate level of respiratory care as required by professional standards of practice.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and according to professional standards of practice, specifically for one resident. During an observation, a surveyor noted that wound care medications, including Santyl ointment, were left in an unlocked drawer in the resident's room. This was contrary to the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments. The resident involved was admitted to the facility with diagnoses including paraplegia and a pressure ulcer of the sacrum. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15. During an interview, the Unit Manager acknowledged that the Santyl ointment, a prescription medication, should have been stored in the locked treatment cart rather than in an unlocked drawer in the resident's room.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen where food items were prepared and stored for resident consumption. Specifically, the facility did not ensure that all staff wore hair restraints while in the kitchen and in the vicinity of food preparation areas, which is necessary to prevent contamination and the spread of infections. During an observation, a surveyor noted that Additional Staff #2 was in the kitchen near the stove, speaking with a dietary staff member, without a hair restraint. Several pots containing food were covered with clear plastic wrap on the stove at the time. Additional Staff #2 acknowledged that she entered the kitchen without a hair restraint to ask for assistance, despite knowing the requirement. The Food Service Director confirmed that all individuals entering the kitchen are required to wear hair restraints, and Additional Staff #2 should have complied with this policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, leading to potential risks of infection transmission. Resident #292, who was readmitted to the facility with Methicillin-Resistant Staphylococcus Epidermidis (MRSE), was not placed under Contact Precautions as recommended by the Centers for Disease Control and Prevention (CDC) guidelines. Instead, the Infection Preventionist (IP) opted for Enhanced Barrier Precautions (EBP), which did not require staff to wear gowns and gloves upon entering the resident's room unless performing high-contact care activities. This decision was made despite the facility's policy indicating that Contact Precautions should be implemented for residents with MRSA infections. Observations revealed that staff did not consistently adhere to the precautionary measures. A staff member was seen sitting at the bedside of Resident #292 without wearing a gown or gloves, and another staff member, CNA #1, confirmed that gowns and gloves were only used during high-contact care. The IP admitted to not using the Contact Precautions sign because of personal preference and a belief that the EBP sign was clearer for staff. This deviation from established guidelines and facility policy increased the risk of MRSE transmission within the facility. Additionally, the facility failed to ensure proper catheter care for Resident #287, who had an indwelling urinary catheter. The catheter tubing was observed lying on the floor on multiple occasions, which CNA #2 acknowledged as inappropriate due to the risk of contamination from the dirty floor. The Infection Control Preventionist (ICP) confirmed that catheter tubing should never be on the floor to prevent infection. These lapses in infection control practices highlight significant deficiencies in the facility's adherence to infection prevention protocols.
Failure to Include Resident Census in Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to comply with the requirement to post complete nurse staffing information on a daily basis. On two consecutive days, the surveyor observed that the nurse staffing information posted in the facility's main lobby was missing the resident census data, which is a required component of the posting. The postings included the facility's name, the current date, and the total number and actual hours worked by RNs, LPNs, and CNAs, but the row designated for the resident census was left blank. During an interview, the Scheduler, who is responsible for completing the daily nurse staffing postings, acknowledged that she had access to the necessary information, including the resident census, but admitted that she had never included it in the postings. She indicated that she could start including the resident census information if required.
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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 Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Skilled Nursing Facility | 3.1 mi | — | 0 | 0 |
| Carlyle House | 3.6 mi | — | 2 | 0 |
| Timothy Daniels House | 4 mi | — | 1 | 0 |
| Casa De Ramana Rehabilitation Center | 4.2 mi | — | 0 | 0 |
| Whittier Westborough Transitional Care Unit | 4.9 mi | — | 0 | 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 August 2026) and official state health department websites.