Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 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 Shores Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple fall risk factors experienced several falls, including one resulting in a rib fracture, due to the facility's failure to promptly update and implement person-centered fall prevention interventions in the care plan. Delays in care plan updates and inconsistent communication led to staff not being aware of or implementing required interventions at the time of the incidents.
Six residents with severe cognitive impairments and significant medical needs were not provided a dignified dining experience, as staff assisted them with eating while standing over them and served their meals earlier in a separate area, without offering them the choice to eat in the main dining room. Staff interviews indicated these practices were implemented for staff convenience rather than resident preference, contrary to facility policy requiring dignity and resident choice during meals.
Staff did not monitor or record food temperatures during breakfast service, with items such as eggs, sausage, and gravy kept in crock pots on the warm setting and served to residents without temperature checks. Dietary and nursing staff confirmed that no one was responsible for checking breakfast food temperatures, and the facility could not provide temperature logs for these meals, despite policy requiring such monitoring.
The facility did not accurately submit direct care staffing data to CMS for one quarter, as the PBJ report indicated a lack of 24-hour licensed nursing coverage on multiple dates despite timecards showing full coverage. Facility leadership was unaware of the submission issue and could not explain the discrepancy, and no PBJ policy was provided.
Surveyors found that hand sanitizer dispensers throughout the facility contained a non-alcohol-based product, contrary to CDC guidelines and facility policy. Staff failed to properly disinfect shared equipment, such as a mechanical lift, and did not consistently follow hand hygiene and glove use protocols during resident care. Additionally, an overnight urine collection bag was not cleaned before storage as required. These deficiencies were observed in the care of multiple residents with significant medical needs.
A resident with diabetes was incorrectly coded in the MDS as receiving insulin injections, when in fact the resident was prescribed dulaglutide, a GLP-1 receptor agonist, and did not receive insulin during the assessment period. This error was confirmed by both an LPN and the MDS coordinator after reviewing the medication records.
A deficiency was found when an oxygen tank was observed free standing in a resident's room instead of being secured in a holder. The resident, who had COPD and required oxygen therapy, was present in the room at the time. Staff, including the maintenance director, associate administrator, LPN, and DON, all confirmed that oxygen tanks should always be secured for safety, and the facility could not provide a policy on oxygen storage.
A resident with multiple respiratory diagnoses did not have their bipap machine water chamber emptied and dried daily as ordered. Observations showed water remaining in the chamber over several days, and the care plan did not address respiratory equipment care. Staff interviews confirmed the required daily maintenance was not performed.
The facility failed to provide dignified assistance with ADLs for two residents. One resident, with a history of stroke and anxiety, was not offered shaving assistance despite expressing a preference for it, and the care plan lacked documentation of this preference. Another resident, with traumatic brain injury and vision impairment, was fed by a standing nursing assistant, contrary to the facility's policy of sitting at the resident's level. Staff interviews revealed inconsistencies in policy implementation, contributing to the deficiency.
A resident with a history of stroke and anxiety disorder required assistance with transfers using a gait belt, as per their care plan. However, staff failed to use the gait belt during observed transfers, and there was confusion among staff about the resident's care needs. The interim DON and director of therapy confirmed the necessity of the gait belt, indicating a lapse in following the care plan.
The facility failed to maintain safe hot water temperatures, placing 24 residents at risk for burns. During a resident screening, excessively hot water was found in a resident's bathroom and the east kitchenette. The maintenance director confirmed weekly checks but acknowledged temperatures as high as 125 and 130 degrees Fahrenheit, which were too hot. The administrator and MD recognized the danger and confirmed the facility's hot water was running too hot, contrary to policies and state regulations requiring temperatures between 105 and 115 degrees Fahrenheit.
A resident with mild cognitive impairment was found with medications left at bedside without a completed SAM form or provider orders. Staff admitted to leaving the medications for the resident to take later, contrary to facility policy requiring a SAM assessment and provider orders.
A facility failed to provide privacy during personal care for a resident with Alzheimer's and other conditions. The NA did not fully close the privacy curtain or the curtain to the outside window, exposing the resident's genital area. Interviews confirmed that staff did not follow proper procedures to ensure privacy.
The facility failed to complete ordered laboratory tests and orthostatic blood pressure measurements for a resident with multiple diagnoses, including Alzheimer's and anemia. Despite orders for a CBC every three months and monthly orthostatic blood pressure measurements, these were not carried out, as confirmed by the DON and CP.
The facility failed to administer medications as per physician orders for two residents. One resident received only 20 mg of omeprazole instead of the prescribed 40 mg, and another resident received only 0.5 mg of ropinirole instead of the prescribed 1 mg in the morning. Both errors were confirmed by the DON.
A facility failed to ensure proper hand hygiene and glove use during personal care for a resident with Alzheimer's and other conditions. A nursing assistant performed peri-care and other tasks without changing gloves or washing hands, potentially spreading infection. The deficiency was confirmed by interviews and a review of the facility's hand washing policy.
A resident's bathroom was found to be missing a call light, which was confirmed by both a nursing assistant and the maintenance director. The resident had multiple diagnoses and was dependent on staff for assistance with activities of daily living.
Failure to Timely Update and Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure that person-centered fall interventions were care planned and implemented for a resident at risk for falls, resulting in actual harm. The resident had multiple diagnoses, including metabolic encephalopathy, neurocognitive disorder with Lewy bodies, anxiety disorder, and severe cognitive impairment, and required assistance with all activities of daily living. The care plan identified the resident as a fall risk due to a history of falls, impaired gait and mobility, and other medical conditions. Despite this, there were lapses in updating and implementing fall prevention interventions following incidents. The resident experienced several falls, including one that resulted in a rib fracture. After a fall on one occasion, a floor mat was identified as a new intervention, but it was not added to the care plan until a later date. Similarly, after another fall, a soft touch call light was determined to be an appropriate intervention, but this was also not promptly updated in the care plan. Staff interviews revealed that not all staff were aware of the required interventions at the time of the incidents, as these were not reflected in the care plan or care guide sheets used by staff. Observations confirmed that some interventions, such as the floor mat, were not present in the resident's room at the time of a fall. Documentation and staff statements indicated that the process for updating care plans and communicating new interventions to staff was inconsistent. The interdisciplinary team (IDT) would determine interventions after reviewing incidents, but there were delays in updating the care plan and care sheets, leading to gaps in staff awareness and implementation of fall prevention measures. As a result, the resident did not consistently receive the interventions identified as necessary to prevent further falls and injury.
Failure to Promote Dignified Dining Experience for Residents Requiring Assistance
Penalty
Summary
The facility failed to promote a dignified dining experience for six residents with severe cognitive impairments who required assistance with eating. Observations revealed that staff, including nursing assistants and an LPN, assisted these residents with meals while standing over them, rather than sitting at their level, and sometimes while performing other tasks. Residents who required feeding assistance were served their meals earlier than other residents and in a separate dinette area, rather than being given the option to eat in the main dining room with others. Staff interviews confirmed that this practice was implemented to make it easier for staff to manage meal service, rather than based on resident preference or choice. The affected residents had significant medical histories, including dementia, Alzheimer's disease, traumatic brain injury, and other cognitive or physical impairments, and their care plans directed staff to provide meal set-up and assistance as needed. Despite these directives, the facility's approach did not encourage resident choice or dignity, as most of the residents receiving early trays were unable to choose whether they would have preferred to eat in the main dining room. Facility policy required that residents be encouraged to eat in the dining room and be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting with meals and avoiding the use of labels such as "feeders."
Failure to Monitor Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food temperatures were monitored prior to and during meal service, as required to prevent the risk of food-borne illness. Observations revealed that breakfast items such as scrambled eggs, sausage, and gravy were kept in crock pots set to the warm setting on both units, and staff served food directly from these crock pots without checking or recording food temperatures. This practice was observed over multiple days, with crock pots remaining on the warm setting for extended periods, and no evidence that temperatures were checked at any point during or after meal service. Interviews with dietary and nursing staff confirmed that food temperatures were not being monitored for breakfast, and staff were unsure who was responsible for this task. The facility was unable to provide breakfast temperature logs when requested, and the administrator acknowledged that breakfast was not included in their food temperature monitoring logs. The facility's own policy required that proper hot and cold food temperatures be maintained and monitored throughout meal service, but this was not followed for breakfast meals.
Failure to Accurately Submit Staffing Data to CMS
Penalty
Summary
The facility failed to ensure that complete and accurate direct care staffing information was electronically submitted to CMS for one of four quarters reviewed. Specifically, the Payroll Based Journal (PBJ) report for quarter 3 of 2024 indicated that the facility did not have licensed nursing coverage for 24 hours on several dates, and also triggered a low weekend staffing metric. However, a review of timecards for the listed dates showed that licensed nursing staff were present and provided 24-hour coverage on each date. During an interview, the administrator, associate administrator, and corporate nurse were unaware of any issues with the staffing data submission and could not explain the discrepancy, though the associate administrator speculated it might be related to agency staff usage. No policy on PBJ submission was provided.
Infection Control Deficiencies: Hand Hygiene, Equipment Disinfection, and Catheter Care
Penalty
Summary
The facility failed to ensure the use of alcohol-based hand sanitizer in hand hygiene dispensers throughout the building. During an observation, a hand sanitizer dispenser was found to contain a product labeled as benzalkonium chloride, not an alcohol-based sanitizer. Both the associate administrator and the DON were unaware that the product in use was not alcohol-based, and it was confirmed that all resident rooms had the same product. The nurse consultant verified that the product did not meet the CDC's recommendation of at least 60% alcohol content for hand sanitizers. Facility policy also required the use of alcohol-based hand sanitizer when soap and water were unavailable, but this was not followed. The facility also failed to ensure proper disinfection of shared equipment and adherence to hand hygiene and glove use protocols. A mechanical lift used for a resident on enhanced barrier precautions was not disinfected with appropriate cleaning wipes after use; instead, personal care wipes were used, which was not acceptable according to the DON. Additionally, staff did not change gloves or perform hand hygiene after providing incontinence care to two residents. In one instance, staff applied protective ointment and handled clean items with soiled gloves, and in another, a staff member wore the same gloves while assisting with multiple tasks and did not perform hand hygiene until much later. The DON stated that staff were expected to change gloves and clean their hands after such care, but this was not observed. Furthermore, the facility did not ensure that an overnight urine collection bag was cleaned prior to storage for a resident with a condom catheter. The bag and tubing were placed back into a privacy bag without being rinsed out, contrary to the expectations stated by the LPN and DON. Requested policies on equipment disinfection and care plans for some residents were not provided during the survey.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to ensure the accurate coding of Section N of the Minimum Data Set (MDS) for one resident reviewed for unnecessary medications. The resident, who had a diagnosis of diabetes mellitus, was documented in the MDS as having received insulin injections twice during the assessment period. However, a review of the provider's orders and the resident's medication administration record revealed that the resident was prescribed dulaglutide, a GLP-1 receptor agonist, administered once weekly, and was not receiving insulin during the look-back period. This discrepancy was confirmed by both an LPN and the MDS coordinator, who acknowledged the inaccuracy in the MDS coding. A policy regarding MDS completion and accuracy was requested but not provided.
Unsecured Oxygen Tank Found in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen tank was found free standing in a resident's room rather than being secured in a designated holder. The resident involved had chronic obstructive pulmonary disease (COPD), depression, and anxiety, and required substantial to maximum assistance with activities of daily living. The resident was observed using oxygen via nasal cannula as ordered. During an observation, one oxygen tank was noted to be free standing near a stationary holder that contained five other secured tanks. Multiple staff members, including the maintenance director, associate administrator, LPN, and DON, confirmed that oxygen tanks should always be secured for safety reasons. The maintenance director and DON both stated that an unsecured tank could become a hazard if knocked over. Staff also verified that they receive training on oxygen safety as part of hazard training. When requested, the facility was unable to provide a policy on oxygen storage.
Failure to Maintain Bipap Machine Water Chamber as Ordered
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper maintenance of a bipap machine for a resident with acute and chronic respiratory failure, COPD, acute bronchospasms, and sleep apnea. The resident's provider orders specified that the bipap water chamber should be emptied, dried, and refilled with distilled water daily at bedtime. However, multiple observations over several days revealed that the water chamber remained partly full and was not emptied or dried between uses. The resident confirmed that staff were responsible for filling the chamber, but stated that no one had come to empty and rinse it out as required. Interviews with staff, including an LPN and the DON, confirmed that the expected practice was to empty and dry the bipap water chamber daily to help prevent possible infections. The resident's care plan did not address the care of oxygen and bipap equipment, and the facility was unable to provide a policy regarding respiratory equipment care when requested. These actions and omissions led to the failure to provide safe and appropriate respiratory care for the resident.
Failure to Provide Dignified ADL Assistance
Penalty
Summary
The facility failed to ensure that residents were assisted with activities of daily living (ADLs) in a dignified manner, specifically for two residents. One resident, who had a history of cerebral infarction and anxiety disorder, expressed a preference for being shaved every two to three days. However, the resident's care plan lacked documentation of this preference, and staff did not offer assistance with shaving on the day of observation, despite the resident's visible whiskers and stated preference for being shaved. The staff's failure to document and respect the resident's grooming preferences led to a deficiency in providing dignified care. Another resident, diagnosed with traumatic brain injury, mood disorder, and dysphagia, required assistance with eating due to vision impairment. During an observation, a nursing assistant was seen standing over the resident while feeding her, rather than sitting at the resident's level, which is considered more respectful and less intimidating. The nursing assistant admitted to multitasking and not sitting while assisting the resident with her meal, which did not align with the facility's expectations for providing dignified care during meals. Interviews with staff, including nursing assistants and the interim director of nursing, revealed inconsistencies in the understanding and implementation of the facility's policies regarding resident care. Staff were expected to offer assistance with shaving and to sit at the resident's level during meals, but these practices were not consistently followed. The lack of documentation and adherence to the facility's policies contributed to the deficiency in providing dignified care to the residents.
Failure to Implement Care Plan During Resident Transfers
Penalty
Summary
The facility failed to implement a resident's care plan appropriately during transfers, as observed in the case of a resident with a history of cerebral infarction and anxiety disorder. The care plan, dated 10/4/24, specified that the resident required assistance from one staff member with a front-wheeled walker and a gait belt for transfers due to mobility issues related to an ischemic stroke. However, during an observation, a nursing assistant assisted the resident with transfers without using a gait belt, contrary to the care plan's instructions. The nursing assistant acknowledged the oversight but noted the absence of a gait belt in the resident's room or on the wheelchair. Interviews with various staff members revealed inconsistencies in their understanding of the resident's care needs and the use of gait belts. While some staff members were unaware of the requirement for a gait belt, others incorrectly believed it was not necessary. The interim director of nursing and the director of therapy confirmed that the care plan required the use of a gait belt for the resident's safety during transfers. The facility's policy on care planning emphasized the importance of using the care plan to guide daily care routines, highlighting a failure in communication and adherence to established protocols.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure that hot water temperatures were maintained at safe levels, placing 24 residents who were independent with their mobility at risk for potential burns. During a resident screening, the water temperature in a resident's bathroom was found to be very hot to the touch. An LPN verified the temperature felt too hot and planned to report it to maintenance. Further checks revealed that the water temperature in the east kitchenette was also excessively hot. The maintenance director (MD) confirmed that he was checking water temperatures weekly and aimed to keep them between 114 - 116 degrees Fahrenheit. However, measurements taken during the survey showed temperatures as high as 125 and 130 degrees Fahrenheit in different locations within the facility, which the MD acknowledged were too hot. The facility's water temperature logs indicated a previous instance of high water temperature (121 degrees Fahrenheit) but did not show any corrective actions taken. The administrator confirmed that the facility aimed to keep water temperatures at 120 degrees Fahrenheit or below, based on maintenance guidance, but later acknowledged that safe temperatures should be between 105 and 115 degrees Fahrenheit. The administrator and MD both verified that the facility's hot water was running too hot and recognized the potential danger of burns to residents. Facility policies and state regulations also specified that hot water should be maintained within the 105 to 115 degrees Fahrenheit range to prevent scalding, and staff were directed to report any excessive water temperatures.
Failure to Perform SAM Assessment and Obtain Provider Orders
Penalty
Summary
The facility failed to perform a self-administration of medication assessment and obtain provider orders for a resident with mild cognitive impairment. During an observation, a medication cup with four pills was found on the resident's bedside table without any staff present. A trained medication aide admitted to leaving the medications for the resident to take later, without confirming if a self-administration of medication (SAM) form was filled out. Interviews with staff, including a licensed practical nurse and the director of nursing, confirmed that the resident did not have a SAM form completed or provider orders to self-administer medications. The facility's policy required a SAM assessment and provider orders before allowing residents to self-administer medications, which was not followed in this case.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy during personal care for a resident diagnosed with Alzheimer's disease, dementia, depression, muscle weakness, and benign prostatic hyperplasia. The resident was moderately cognitively intact, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for assistance with activities of daily living. During an observation, a nursing assistant (NA) entered the resident's room without fully closing the privacy curtain or the curtain to the outside window facing the parking lot. The NA proceeded with personal care, exposing the resident's genital area while the curtains remained open, allowing visibility from the parking lot and the hallway. The NA continued to perform tasks such as emptying the catheter bag without changing gloves and left the resident's gown up and covers down, further compromising the resident's privacy. Interviews with the NA, a licensed practical nurse (LPN), and the director of nursing (DON) confirmed that the privacy curtains were not properly closed before care was performed. The DON verified that staff are expected to ensure privacy by closing both the privacy curtain and the curtain to the outside before starting personal care to maintain the resident's dignity and privacy.
Failure to Complete Ordered Laboratory Tests and Orthostatic Blood Pressure Measurements
Penalty
Summary
The facility failed to ensure that ordered laboratory tests and orthostatic blood pressure measurements were completed for a resident (R13) who was reviewed for unnecessary medications. R13 had multiple diagnoses including Alzheimer's disease, dementia, depression, muscle weakness, anemia, hypertension, and normal pressure hydrocephalus. The resident was moderately cognitively intact and dependent on staff for activities of daily living. Despite having orders for a complete blood count (CBC) every three months and monthly orthostatic blood pressure measurements, these were not carried out as required. The director of nursing (DON) confirmed that the CBC order was not followed and that orthostatic blood pressures were not measured as ordered, which could lead to unmonitored low hemoglobin levels and untreated conditions. The resident's care plan included monitoring for side effects and effectiveness of medications, as well as documenting and reporting signs and symptoms of anemia. However, a review of the resident's laboratory results and vital signs summary showed that the required tests were not performed. The consultant pharmacist (CP) also stated that staff should follow provider orders and contact the provider if they were unable to carry out the orders. The facility's medication and treatment orders did not address what staff should do when they were unable to complete an order, contributing to the deficiency in care for the resident.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for two residents. For Resident 11, who has diagnoses including gastro-esophageal reflux disease, abnormal weight loss, anxiety, and Crohn's disease, the physician ordered 40 mg of omeprazole to be administered in the morning. However, during observation, an LPN prepared and administered only 20 mg of omeprazole, mistakenly believing the order had changed. The error was confirmed by the Director of Nursing (DON) after consultation with the LPN. For Resident 187, who has diagnoses including Parkinson's disease, major depression, and hypertension, the physician ordered 1 mg of ropinirole to be administered in the morning. However, a trained medication aid (TMA) prepared and administered only 0.5 mg of ropinirole, incorrectly stating that the resident should receive 0.5 mg in the morning and another 0.5 mg at noon. This error was also confirmed by the DON upon review of the MAR and medication label. The facility did not provide a policy specifically addressing how to administer medications when requested.
Failure to Maintain Proper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use practices during personal care for a resident diagnosed with Alzheimer's disease, dementia, depression, muscle weakness, and benign prostatic hyperplasia. The resident was moderately cognitively intact, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for assistance with activities of daily living. During an observation, a nursing assistant (NA) was seen performing peri-care and other tasks without changing gloves or performing hand hygiene, despite handling various items in the resident's room, including the resident's beverage cup and call light. The NA only washed his hands after leaving the resident's room, which was confirmed during an interview with the NA and the licensed practical nurse (LPN). The facility's hand washing policy required staff to perform hand hygiene before donning gloves and after removing them, especially after changing incontinent products or cleaning up after someone who has used the toilet. The director of nursing (DON) confirmed that staff were expected to change gloves and perform hand hygiene during peri-care to prevent contamination and infection. The NA's failure to change gloves and perform hand hygiene as required by the facility's policy had the potential to spread infection. The deficiency was identified through observation, interview, and document review, highlighting a lapse in adherence to infection prevention and control protocols within the facility.
Missing Bathroom Call Light for Resident
Penalty
Summary
The facility failed to provide a bathroom call light for a resident (R13) who was reviewed for call lights. R13's quarterly Minimum Data Set (MDS) indicated that he had diagnoses including Alzheimer's disease, dementia, depression, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms. R13 was moderately cognitively intact, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for assistance with activities of daily living. During a resident screening, it was observed that R13's bathroom had no call light. This was verified by a nursing assistant (NA-B) and the maintenance director (MD-A), who both confirmed that any resident using R13's bathroom would have no means to call for help. The administrator also verified that each resident bathroom should have a call light to ensure residents can call for help if needed.
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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 Two Harbors
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ecumen Lakeshore | 22.8 mi | — | 0 | 0 |
| Aftenro Home | 25 mi | — | 17 | 0 |
| Benedictine Health Center | 25.4 mi | — | 22 | 2 |
| Hilltop Healthcare Rehabilitation And Skilled Nurs | 26.2 mi | — | 17 | 0 |
| Minnesota Veterans Home - Silver Bay | 26.5 mi | — | 9 | 0 |
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