Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 The Waterview Pines Llc during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with dementia and mobility issues was transferred using a toileting sling instead of the care-planned full body sling, resulting in a fall from the lift and head injury. The staff did not report the incident to the state agency as required by facility policy, despite evidence that the transfer method was inappropriate for the resident's condition.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
The facility failed to maintain adequate staffing levels, resulting in delayed care and unmet needs for residents. Interviews revealed long call light wait times, insufficient personal care, and reliance on undertrained agency staff. Specific incidents included residents left soiled, delayed morning care, and untimely pain medication administration. The facility's staffing assessment was not met, impacting care during emergencies. The resident council expressed ongoing concerns about staffing, with no satisfactory response from administration.
A resident with chronic respiratory conditions was found with an oxygen humidifier bottle that had not been changed for over a month, contrary to facility policy. The facility's order summary lacked a schedule for changing the oxygen bubbler, and there was no documentation in the resident's electronic medical record. Both a registered nurse and the DON confirmed the expectation for regular changes, but the facility could not provide the relevant policies.
The facility failed to ensure timely repositioning and coordination of care for a hospice patient, did not follow weight monitoring orders for a resident with CHF, and did not complete dressing changes as ordered for a resident with an amputation. Additionally, the facility failed to ensure the placement of an AFO for a resident and did not deliver medications timely for a resident experiencing significant pain. These deficiencies highlight a pattern of inadequate care coordination and documentation.
A facility failed to provide adequate supervision for a resident with dementia, multiple sclerosis, depression, and dysphagia during dining. The resident, who required assistance with eating, was left alone in the dining room while a dietary staff member cleared tables. The resident remained unsupervised until a nursing assistant arrived to escort her to her room. Interviews with the RN and DON confirmed the need for nursing staff presence during meals for safety, as per facility policy.
The facility failed to dispose of an expired bottle of half and half, which was still accessible to residents. The culinary aide and director confirmed the product should have been discarded five days after opening or by the expiration date. The infection preventionist highlighted the increased risk of bacteria and foodborne illness from using expired dairy products. The facility's policy lacked guidance on monitoring expiration dates.
A resident with cognitive intactness and multiple diagnoses, including anxiety, was not provided adequate personal hygiene care, leading to greasy hair and discomfort. Despite the resident's care plan indicating a need for assistance and proactive care, the facility only scheduled weekly showers, failing to maintain the resident's dignity. Staff acknowledged the oversight, emphasizing the importance of offering hair washing without the resident having to request it.
A resident with cognitive impairment and multiple diagnoses was not assisted in getting dressed and going to the dining room for breakfast due to staffing shortages. The resident's care plan indicated a preference for dining in the main dining room and being ready by 8:00 a.m., but staff were unable to meet these preferences consistently. The facility's policy emphasized person-centered care, yet the resident's rights and dignity were compromised.
A resident's concern about a broken toilet went unaddressed due to a lack of communication and reporting among staff. The cracked toilet bowl was not reported by housekeeping or nursing staff, and no maintenance request was submitted. The regional director of maintenance confirmed the need for replacement, highlighting a failure in the facility's process for reporting and repairing broken equipment.
The facility failed to complete all sections on the MDS for two residents, leading to deficiencies in their assessments. One resident's cognitive and mood assessments were not conducted, while another resident's use of a wanderguard was not documented. These oversights were confirmed by facility staff, highlighting the need for accurate assessments to ensure proper care and billing.
The facility failed to address ADLs for two residents. One resident with a self-care deficit had neglected nail care, while another resident, dependent on staff for transfers, was left in bed undressed and unable to attend meals as preferred. Staff shortages and lack of documentation contributed to these deficiencies.
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies. One resident did not receive documented education or proper heel elevation, while another experienced gaps in weekly skin inspections and delayed notification to the RD about wound care needs. The DON acknowledged the importance of following care plans and conducting regular inspections, but the facility's failure to adhere to protocols resulted in these deficiencies.
A resident with traumatic brain injury and hemiplegia was not provided with a palm protector as outlined in their care plan, leading to a deficiency in care. The resident's left hand was found in a fist, and staff were unable to locate the palm protector. The director of nursing confirmed that the care plan was not followed, which could prevent further contractures.
A facility failed to ensure PRN lorazepam orders were time-limited to 14 days and lacked a documented diagnosis for a resident with severe cognitive impairment. The resident's care plan included psychotropic drug monitoring, but the order for lorazepam was set for six months without a rationale for extending beyond 14 days, contrary to facility policy. After discharge from hospice, a new order with an indication and rationale should have been documented.
A facility failed to secure a resident's hospice medical records. The resident, with dementia and congestive heart failure, had hospice care orders not integrated into the EHR. Hospice staff recorded notes on paper stored in a binder, which went missing. Efforts to locate the chart were unsuccessful, and the facility's record retention policy did not address security.
The facility failed to post daily nurse staffing information over the weekend, impacting all 53 residents and visitors. An observation found the staffing sheet dated from the previous Friday, and the administrator confirmed that the charge nurse was responsible for updating and posting the sheets daily, including weekends.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report Suspected Neglect After Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency after a resident experienced a fall from a mechanical lift. The resident, who had diagnoses including dementia with behavioral disturbance, back pain, chronic pain, and spinal stenosis, was care planned to be transferred using a ceiling lift with a toileting sling for toileting and a full body split leg sling for all other transfers. On the date of the incident, staff transferred the resident from the wheelchair to the bed using a toileting sling, contrary to the care plan, and the resident fell out of the sling and hit her head. The nursing assistant involved stated the resident, who was confused and tired, placed her arms inside the sling during the transfer, despite being instructed to keep them outside. The ceiling lift representative confirmed that the toileting sling required the resident to keep their arms outside and that the sling may not have been appropriate for someone with cognitive or physical limitations. Despite the incident, the administrator and DON did not report the event to the state agency, stating that the care plan had been followed, even though documentation and interviews indicated otherwise. Facility policy required all suspected abuse or neglect, defined as failure to provide necessary goods and services to avoid harm, to be reported to the state agency within two hours of suspicion. The failure to report the incident as required constituted a deficiency in timely reporting of suspected neglect.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Inadequate Staffing Leads to Delayed Care and Resident Neglect
Penalty
Summary
The facility failed to ensure adequate staffing levels, resulting in delayed and insufficient care for residents. Multiple interviews with staff, residents, and family members highlighted significant concerns about the lack of staff, particularly during weekends and night shifts. Residents experienced long wait times for call lights, leading to incidents of incontinence and unmet personal care needs. Family members reported having to assist with care themselves due to the lack of available staff. The use of agency staff without proper training further exacerbated the issue, as regular staff had to spend time guiding them, detracting from their own duties. Specific incidents included a resident being left soiled for extended periods, another resident not receiving morning care until the afternoon, and a resident not receiving timely pain medication. The facility's staffing assessment indicated a need for a certain nurse-to-resident and NA-to-resident ratio, but actual staffing levels fell short, with hours of care per resident per day ranging from 1.6 to 2.2, below the required 2.8 to 3.2. The facility's administration acknowledged the staffing issues but believed their ratios supported the care being provided, despite evidence to the contrary. The deficiency was further highlighted by the facility's inability to manage care during emergencies or unexpected events, such as a resident's death, which impacted the care of other residents. The facility's policy on Activities of Daily Living emphasized person-centered care, but the lack of staff prevented the fulfillment of residents' preferences and needs. The resident council and ombudsman also expressed concerns about staffing, indicating that the issue was a recurring topic in their meetings, with no satisfactory response from the administration.
Failure to Implement Respiratory Care Orders
Penalty
Summary
The facility failed to implement orders for respiratory care for a resident with multiple chronic respiratory conditions. The resident was observed lying in bed with oxygen administered via nasal cannula at 2 liters per minute, with the oxygen being humidified. The humidifier bottle was dated over a month prior, indicating it had not been changed as expected. The resident's medical history included centrilobular emphysema, chronic obstructive pulmonary disease, pulmonary fibrosis, atherosclerosis of the aorta, morbid obesity with alveolar hypoventilation, and chronic respiratory failure with hypoxia. The facility's order summary for the resident included instructions to fill the concentrator bubbler every evening shift, but did not specify a schedule for changing it. A review of the resident's electronic medical record revealed no documentation of the oxygen bubbler being changed. A registered nurse confirmed the lack of documentation and stated that the oxygen bubbler should be changed monthly according to policy for infection control purposes. The director of nursing also confirmed the expectation for regular changes of oxygen bubblers per policy, but the facility was unable to provide the relevant respiratory care policies upon request.
Deficiencies in Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure timely repositioning and coordination of care for a hospice patient, identified as R8, who experienced a change in condition. R8, who had moderately intact cognition and diagnoses of dementia and congestive heart failure, was dependent on staff for various activities of daily living. Despite orders for repositioning every three hours and communication with hospice for changes in condition, R8 was not repositioned for over four hours, and hospice was not notified of her unresponsiveness and lack of intake. Observations revealed that staff were unaware of the last repositioning time, and there was a lack of coordination in administering medications appropriately. The facility also failed to follow provider orders for weight monitoring for a resident, identified as R26, with congestive heart failure and chronic kidney disease. The resident's care plan did not address weight monitoring, and there were multiple lapses in weekly weight checks, which could lead to fluid overload. The Director of Nursing acknowledged these lapses and the associated risks. Additionally, the facility did not complete dressing changes as ordered for a resident, identified as R40, with an above-the-knee amputation and surgical wounds. The dressing change was not documented, and the resident reported that the dressing had not been changed as scheduled. The facility also failed to ensure the placement of an ankle-foot orthosis for a resident, identified as R32, and did not deliver medications timely for a resident, identified as R1, who experienced significant pain due to delayed medication administration. These deficiencies highlight a pattern of inadequate care coordination and documentation within the facility.
Lack of Supervision During Dining for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during dining, leading to a deficiency. The resident, who was diagnosed with dementia, multiple sclerosis, depression, and dysphagia, was identified as severely cognitively impaired and required partial to moderate assistance with eating. On the evening of November 18, 2024, the resident was observed alone in the dining room, eating and drinking without supervision from nursing staff or trained feeding staff. A dietary staff member was present but was engaged in clearing tables rather than supervising the resident. The resident remained unsupervised until a nursing assistant arrived to escort her to her room. Interviews with the RN and DON confirmed that nursing staff should be present in the dining room during meals to ensure safety, particularly in the event of choking. The facility's policy, dated August 26, 2020, stated that a nursing assistant or other designated, trained personnel should be assigned to the dining room at all meals to assist residents with food preparation and feeding.
Expired Dairy Product Not Disposed of in Facility
Penalty
Summary
The facility failed to dispose of an expired bottle of half and half dairy product, which was still available for residents to use. An opened bottle of half and half was found in the refrigerator of the dining hall dinette room with a handwritten open date and a manufacturer's expiration date. The culinary aide confirmed the dates and acknowledged that the dairy product should have been discarded five days after opening or by the manufacturer's expiration date. The culinary director reiterated that dairy products should be disposed of after five days of being opened or by the expiration date. The infection preventionist noted that using dairy products past their expiration date increases the risk of bacteria and foodborne illness. The facility's policy on food receiving and storage, last revised in 2017, did not include information on monitoring foods and liquids for expiration dates.
Failure to Maintain Resident Dignity Through Adequate Hygiene Care
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as R52, by not providing adequate personal hygiene care. R52, who was cognitively intact and had diagnoses including diabetes, depression, hemiplegia, and hemiparesis, required moderate assistance for personal hygiene and maximal assistance for showering. The resident's care plan indicated that R52 was shy, had anxiety, and often did not ask for help, leading to incontinence issues. Despite these needs, R52 was only scheduled for a shower once a week, which was insufficient as their hair became greasy quickly, causing discomfort and a feeling of uncleanliness. Interviews and observations revealed that R52's hair appeared greasy on multiple occasions, and the resident expressed a desire for more frequent hair washing. Staff, including a nursing assistant and a registered nurse, acknowledged that residents should not have to request hair washing if it was visibly needed, and it should be offered proactively to maintain dignity. The Director of Nursing also stated that staff should recognize and address such needs without the resident having to ask. The facility's policy on Activities of Daily Living emphasized the importance of person-centered care and maintaining residents' dignity, which was not upheld in this case.
Failure to Honor Resident's Preference for Dining Room Breakfast
Penalty
Summary
The facility failed to honor a resident's preference to be dressed and have breakfast in the dining room, as observed in the case of a resident with significant cognitive impairment and multiple diagnoses, including neurological disorders and dementia. The resident's care plan indicated a preference to dine in the main dining room and to be ready by 8:00 a.m. However, the resident was found shirtless in bed during an interview, expressing frustration about not being able to get dressed and go to the dining room due to insufficient staffing. The resident required maximal assistance for activities of daily living and was dependent on staff for transfers. Interviews with nursing staff revealed that the resident was not consistently assisted in getting up and dressed in the morning due to staffing shortages, particularly because the resident required a two-person transfer. The nursing assistant confirmed that they were unable to meet the resident's preferences on days when only one nursing assistant was scheduled until later in the morning. The director of nursing acknowledged that the resident's preferences should be honored, and the facility's policy emphasized the importance of person-centered care and honoring resident preferences. Despite this, the resident's preferences were not consistently met, leading to a deficiency in resident rights and dignity.
Failure to Report and Repair Broken Toilet
Penalty
Summary
The facility failed to ensure a safe and homelike environment for a resident due to a broken toilet that was not reported or repaired. The resident expressed concern about the cracked toilet bowl, which was observed to be damaged near where the seat attached. Despite the resident's concern, there was no maintenance request submitted to address the issue. Staff members, including LPNs and housekeeping personnel, were unaware of the broken toilet or did not report it. The regional director of maintenance confirmed the need for the toilet bowl to be replaced and noted that no maintenance slip had been filled out. The housekeeping staff assumed the issue had been reported by others, and the housekeeping director was not informed of the problem. The associate administrator and regional director of operations emphasized the importance of reporting and addressing broken equipment to prevent injuries.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete all sections on the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. For one resident, identified as R23, the quarterly MDS did not assess cognitive patterns and mood, despite indications that these assessments should have been conducted. This oversight was confirmed by both a registered nurse and the director of nursing, who acknowledged that these assessments were necessary to ensure the resident received appropriate medication and care planning. Another resident, identified as R14, had an annual MDS that failed to document the use of a wanderguard, a device intended to prevent elopement. The director of nursing verified this omission and emphasized the importance of accurate assessments for billing, payment, and identifying elopement concerns. The facility did not provide a policy on filling out resident assessments, which may have contributed to these deficiencies.
Failure to Address ADLs for Residents
Penalty
Summary
The facility failed to ensure activities of daily living (ADL) were adequately addressed for two residents. One resident, identified as R4, had a care plan indicating a self-care deficit related to traumatic brain injury and hemiplegia, requiring assistance with dressing, grooming, and bathing. Despite this, weekly skin care assessments documented that R4's fingernails and toenails were not addressed on multiple occasions. Observations revealed that R4's fingernails were approximately 1/2 inch in length with a brown substance underneath, indicating neglect in nail care. The Director of Nursing stated that nail care should be completed by nursing assistants on shower days, or by a licensed nurse if the resident is diabetic, but documentation of this care was not provided. Another resident, R32, required maximal assistance for ADLs and was dependent on staff for transfers. R32 expressed frustration about not being dressed and out of bed in time for breakfast, as was their preference. On multiple occasions, R32 was observed shirtless in bed, stating that staff shortages were the reason for the delay in assistance. Interviews with staff confirmed that R32's preferences should have been honored, but they were not consistently met, resulting in the resident remaining in bed for extended periods without being dressed or able to attend meals in the dining room.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. For one resident, identified as R35, the facility did not document education or refusals related to pressure ulcer relief. R35, who had multiple diagnoses including hemiplegia, dementia, and morbid obesity, was observed multiple times without proper heel elevation or the use of prescribed heel boots, despite care plan interventions requiring these measures. Staff interviews revealed that attempts to encourage heel elevation were not consistently documented, and there was no record of education provided to R35 about the importance of these interventions. Another resident, R39, experienced gaps in weekly skin inspections as ordered, and there was a lack of timely notification to the registered dietician (RD) regarding new and worsening wounds. R39, who had diabetes and chronic kidney disease, was dependent on staff for mobility and had developed pressure ulcers while at the facility. The care plan required weekly skin inspections, but records showed significant gaps in these inspections over several months. Additionally, the RD was not promptly informed of the resident's nutritional needs related to wound care, despite changes in the resident's condition and dietary orders. The Director of Nursing (DON) acknowledged the importance of following care plans and conducting regular skin inspections to monitor and address skin integrity issues. However, the facility's failure to adhere to these protocols resulted in deficiencies in the care provided to residents R35 and R39, as evidenced by the lack of documentation and communication regarding their pressure ulcer care and nutritional needs.
Failure to Use Palm Protector for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure the use of a palm protector for a resident with limited range of motion, leading to a deficiency in care. The resident, who had a history of traumatic brain dysfunction, hemiplegia, and traumatic brain injury, was severely cognitively impaired and dependent on staff for activities of daily living. The care plan specified the use of a foam built-up palm protector to reduce contraction in the resident's left hand, which was to be worn overnight and removed in the morning. During observations and interviews, it was noted that the resident's left hand was in a fist and the palm protector was not in use. Staff, including a nursing assistant and an LPN, were unable to locate the palm protector in the resident's room, and the nursing assistant admitted not having seen it for a long time. An occupational therapist confirmed the absence of the palm protector and noted debris on the resident's hand, indicating a lack of proper care. The director of nursing acknowledged that the care plan was not followed, which could prevent further contractures.
Failure to Time-Limit PRN Lorazepam Orders
Penalty
Summary
The facility failed to ensure that PRN orders for lorazepam, a psychotropic medication, were time-limited to 14 days and accompanied by a documented associated diagnosis for a resident with severe cognitive impairment. The resident's care plan included psychotropic drug monitoring and interventions for cognitive and mood alterations, but the order summary for lorazepam lacked a medical diagnosis. The order was set for a duration of six months without a documented rationale for extending the PRN use beyond 14 days, contrary to the facility's policy. The resident was previously on hospice care, during which lorazepam was used for comfort and symptom management. However, after discharge from hospice, the hospice order should have been discontinued, and a new order with an indication and rationale for PRN lorazepam use should have been documented. The facility's policy required that PRN psychotropic medications be prescribed for the shortest period necessary and that any extension beyond 14 days be justified by the healthcare practitioner, which was not done in this case.
Failure to Secure Hospice Medical Records
Penalty
Summary
The facility failed to ensure the security of medical records for a resident receiving hospice care. The resident, who had moderately intact cognition and diagnoses of dementia and congestive heart failure, was dependent on staff for daily activities. The resident's care plan included hospice care through Essentia East Range Hospice, with specific orders to maintain communication with hospice staff. However, the hospice care plan was not integrated into the resident's electronic health record (EHR). During the survey, it was discovered that the facility could not locate the resident's hospice chart. Hospice staff recorded their notes on paper, which were stored in a binder at the nurse's station, rather than in the EHR. Despite efforts by the corporate nurse consultant and the director of nursing to locate the hospice chart, it remained missing. The facility's document on the retention of medical records did not address the security of these records, contributing to the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily over the weekend, which had the potential to impact all 53 residents and visitors who may wish to review this information. During an observation on a Sunday, the posted staffing sheet was found to be dated from the previous Friday, indicating that the staffing information had not been updated for the weekend. For the remainder of the survey period, the daily staffing information sheets were updated and posted each day. In an interview, the administrator acknowledged that staffing hours should be updated and posted daily, including on weekends. The responsibility for updating and posting the staffing sheets on Saturdays and Sundays was assigned to the charge nurse, who failed to post a new staffing sheet each day over the past weekend.
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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 Virginia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Essentia Health Virginia Care Cent | 1 mi | — | 4 | 0 |
| The Waterview Woods Llc | 3.5 mi | — | 18 | 0 |
| Cornerstone Villa | 10.7 mi | — | 4 | 0 |
| Heritage Manor | 15 mi | — | 0 | 0 |
| Essentia Health Northern Pines Medical Center | 15.1 mi | — | 5 | 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.