Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Woods Llc during CMS and state inspections, most recent first.
A resident's bathroom was left with a missing ceiling tile and a wet, stained towel covering an opening above the toilet for at least a month, with ongoing water leakage and standing water present. Staff confirmed the issue persisted, and the infection preventionist noted increased infection risk due to the wet environment.
A resident with multiple serious diagnoses was prescribed buprenorphine 1mg (half of a 2mg tablet) sublingually three times daily, but was given a whole 2mg tablet on six occasions. Documentation and interviews with nursing staff and the acting DON confirmed the error, which was inconsistent with physician orders and facility policy requiring adherence to the five rights of medication administration.
A resident with heart failure and cognitive impairment fell during a transfer using a ceiling lift with an incorrect sling, resulting in a head laceration. The nursing assistant, unfamiliar with the resident, used a half sling found in the room, leading to the resident slipping out and falling. The facility lacked documentation on the correct sling type and size, contributing to the incident.
A facility failed to include specific sling type and size in care plans for residents requiring mechanical lift transfers, leading to a fall incident. One resident with heart failure and aortic stenosis fell during a transfer due to improper sling use, resulting in a head injury. Staff interviews revealed inconsistencies in sling use guidance, and care plans lacked necessary details, despite slings being correct per manufacturer guidelines.
A resident with a known shellfish allergy was served shrimp, resulting in an allergic reaction and emergency treatment. The deficiency was due to a communication failure in documenting and relaying food allergies to kitchen staff. The resident's allergy was not included on the meal ticket, and the dietary sheet lacked a designated area for allergies, leading to the oversight.
The facility did not maintain 8 hours of continuous RN coverage daily, as required, during the third quarter of 2024. This deficiency was confirmed by the CMS PBJ Staffing Data Report, which identified specific dates lacking the required RN presence. The administrator acknowledged the absence of RN coverage and its importance for resident safety. The facility's scheduling and RN coverage policies were not provided.
The facility failed to provide a substantive snack after dinner, resulting in a 15-hour gap between meals, potentially affecting all residents. Interviews revealed that snacks were not readily offered, and residents had to request them. A resident with Parkinson's and diabetes confirmed the absence of an evening snack pass, and LPNs corroborated the lack of a snack cart. The facility's policy of not exceeding 14 hours between meals without a substantial snack was not followed.
The facility failed to ensure proper PPE use for a resident with enhanced barrier precautions, leading to inadequate infection control. Nursing assistants did not wear full PPE during care, and the facility did not conduct necessary COVID-19 testing or infection surveillance among staff. Additionally, the facility lacked an annual review of infection control policies and did not provide evidence-based criteria for infection identification to nursing staff.
A resident with dementia and impaired cognition, requiring supervision during meals, was found eating unsupervised in bed, contrary to their care plan. The resident was on a mechanical soft diet due to swallowing difficulties and was at risk for choking and aspiration. Staff interviews revealed a lack of awareness about the incident, and the DON confirmed the expectation for supervision was not met.
A facility failed to assess and obtain informed consent for bed rail use for a resident with a hip fracture requiring moderate assistance. The resident's care plan and medical record lacked necessary assessments and consent forms. Staff interviews confirmed the absence of required documentation, and the facility's bed rail use policy was not provided.
Failure to Maintain Safe and Clean Resident Environment Due to Ongoing Water Leak
Penalty
Summary
A deficiency was identified when a resident's bathroom was observed to have a missing ceiling tile directly above the toilet, with a wet, stained towel draped across the opening and free-standing water present on the toilet. The resident, who had intact cognition and diagnoses including hypertension, hyperlipidemia, and renal insufficiency, reported that the ceiling tile had been missing and the towel in place for at least a month due to a leak from the room above. Staff interviews confirmed that the condition had persisted for at least a month, with ongoing water leakage resulting in soaked toilet paper and the need to discard it during cleaning. The maintenance director indicated that the leak above had been repaired, but the towel remained to monitor for further leakage. The infection preventionist acknowledged that the presence of wet towels and standing water increased the risk of infection and illness. The regional director of operations stated that such a situation would typically require the resident to be moved and the area repaired before reoccupancy. No policy for environmental services water leakage was provided upon request.
Failure to Administer Correct Dose of Buprenorphine
Penalty
Summary
A deficiency occurred when a resident with diagnoses including a pathological fracture, malignant neoplasm of the esophagus, and aftercare for joint replacement did not receive the correct dose of buprenorphine as ordered by the physician. The physician's order specified that the resident should receive 1mg (half of a 2mg tablet) sublingually three times a day. However, documentation and medication card review revealed that on six separate occasions, the resident was administered a whole 2mg tablet instead of the prescribed half tablet. The medication card was bubble packed with 2mg tablets, and nursing staff were responsible for splitting the tablets to achieve the correct dose. Interviews with an LPN and the acting DON confirmed that the medication sign-out sheet documented the administration of whole tablets rather than half tablets, contrary to the physician's order and facility policy. The facility's policy required nursing staff to follow the five rights of medication administration and to triple check these rights during the process. The failure to administer the correct dose and to document it accurately led to a significant medication error for the resident.
Improper Sling Use Leads to Resident Fall
Penalty
Summary
The facility failed to properly assess, care plan, and ensure the correct sling was used during transfers for a resident reviewed for mechanical lift transfers. The resident was transferred using a ceiling lift with a reported toileting sling of unknown size, which did not cover the buttocks. During the transfer, the resident slipped out of the sling, resulting in a fall and a laceration to the back of the head. This incident was identified as an immediate jeopardy situation. The resident involved had a primary diagnosis of chronic combined systolic and diastolic heart failure and nonrheumatic aortic stenosis, with moderate cognitive impairment. The incident occurred when a nursing assistant, unfamiliar with the resident, used a half sling found in the resident's room for the transfer. The resident began to flail during the transfer, causing them to slip out of the sling and fall to the ground, hitting their head. Interviews with staff revealed that there was a lack of documentation regarding the specific type and size of sling to be used for the resident. The nursing assistant was instructed to use the ceiling lift due to the resident's weakness in the evenings, but the correct sling type and size were not verified. The facility did not have a formal sling assessment form, and the specific sling type and size were not documented in the resident's medical record.
Deficiency in Care Plan for Sling Use in Transfers
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for residents requiring mechanical lift transfers, specifically neglecting to identify the type and size of sling needed. This deficiency was observed in three residents who were reviewed for mechanical lift use. One resident, admitted with chronic heart failure and aortic stenosis, experienced a fall during a transfer when the resident's upper body slid through the sling, resulting in a head injury. The incident report noted that the correct sling and size were used, but the care plan did not specify the sling type or size. Another resident, dependent on staff for transfers due to conditions such as chronic gout and coronary artery disease, also had a care plan that failed to specify the sling type or size. Similarly, a third resident with diagnoses of seizures and arthritis, who was also dependent on staff for transfers, had a care plan lacking this critical information. Interviews with staff revealed that there was confusion and inconsistency in the use of slings, with some staff relying on care sheets that did not provide adequate guidance on sling specifications. The Director of Nursing and other staff members acknowledged the absence of a formal sling assessment form and the lack of documentation regarding sling type and size in the care plans. Observations confirmed that while the slings in resident rooms were correct according to manufacturer guidelines, the care plans did not reflect this information, leading to potential safety risks during resident transfers.
Failure to Prevent Shellfish Allergy Exposure
Penalty
Summary
The facility failed to ensure that a resident with a known allergy to shellfish was not served shellfish, resulting in an allergic reaction. The resident, identified as R209, was admitted to the facility with a documented allergy to shellfish, as noted in both the admission note and care plan dated 10/9/24. Despite this, on 10/13/24, R209 was served a meal containing shrimp, leading to an allergic reaction that required emergency treatment. The incident was identified as an immediate jeopardy situation due to the severity of the allergic reaction. Interviews and document reviews revealed that the communication process for food allergies was flawed. The health unit coordinator (HUC) was responsible for entering allergy information into the electronic medical record (EMR) and completing a dietary sheet for the kitchen staff. However, R209's shellfish allergy was not included on his meal ticket prior to the incident. The culinary director (CD) was the only staff member with access to the dietary system to verify and add food allergies, which contributed to the oversight. Staff interviews indicated that food allergies should be listed on meal tickets and in the EMR, but this was not consistently checked by all staff members. The root cause of the deficiency was identified as a dietary sheet lacking a designated area for allergies, which led to the failure to communicate R209's shellfish allergy to the kitchen staff. This oversight resulted in the resident being served shrimp, despite having a history of severe allergic reactions to shellfish. The facility's policies and procedures for documenting and communicating food allergies were insufficient, leading to the incident where R209 experienced an allergic reaction and required emergency medical attention.
Removal Plan
- All residents were audited for current food allergies.
- The new admission form was modified to add an area specifically to address resident food allergies.
- Dietary policy related to meal tickets was reviewed.
- Resident allergy documentation was reviewed.
- Staff were educated on the meal ticket handling policy and what to do with new admissions form.
Failure to Maintain Continuous RN Coverage
Penalty
Summary
The facility failed to maintain 8 hours of continuous registered nurse (RN) coverage daily, as required. This deficiency was identified through the Centers for Medicare and Medicaid Services' (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of 2024, which showed gaps in RN coverage on multiple dates. Specifically, the facility did not have the required RN coverage on 4/6, 4/7, 4/20, 4/21, 4/27, 4/28, 5/19, 5/25, 5/26, 6/1, 6/2, 6/8, 6/9, and 6/22. During an interview, the administrator confirmed the absence of 8 hours of continuous RN coverage on these dates and acknowledged the importance of having an onsite RN for the safety of the residents. The facility's scheduling policy and RN coverage policy were requested but not provided.
Failure to Provide Substantive Evening Snacks
Penalty
Summary
The facility failed to provide a substantive snack after dinner and before bedtime, resulting in a 15-hour gap between the evening and morning meals, which could potentially affect all residents. Interviews and document reviews revealed that the dietary staff were responsible for restocking snacks, but the nursing staff were tasked with distributing them. However, it was found that there was no evening snack cart, and residents had to request snacks, which were not readily offered by the staff. The kitchen closed at 7 p.m., and the unit fridges, which contained sandwiches, were locked at night, making it difficult for residents to access snacks without staff assistance. A resident with intact cognition and diagnoses of Parkinson's disease and type II diabetes mellitus confirmed the absence of an evening snack pass and the need to request snacks. Interviews with LPNs working both day and evening shifts corroborated the lack of a snack cart and the requirement for residents to ask for snacks. The facility's mealtime document specified that there should not be more than 14 hours between meal services unless a substantial bedtime snack is offered, which was not adhered to, leading to the deficiency.
Inadequate PPE Use and Infection Control Measures
Penalty
Summary
The facility failed to ensure proper utilization of personal protective equipment (PPE) for a resident with enhanced barrier precautions (EBP). The resident, who had severely impaired cognition and was post-colostomy, required staff assistance for various care activities. During an observation, two nursing assistants entered the resident's room for repositioning without wearing the full PPE required for EBP, mistakenly believing that full PPE was only necessary for wound care or COVID-19 cases. Interviews with the nursing staff revealed a lack of understanding and adherence to the EBP requirements, despite the facility's expectations for PPE use during high-contact care. Additionally, the facility did not conduct adequate COVID-19 outbreak testing or infection surveillance among staff members. Despite having two current positive COVID-19 cases among residents, the director of nursing (DON) confirmed that no staff testing had been conducted, relying instead on contact tracing and symptom monitoring. The DON admitted to not performing any surveillance of staff for signs or symptoms of illness and acknowledged the absence of a structured approach to infection surveillance. The facility also failed to annually review its infection control policies and procedures, maintain a current list of reportable communicable diseases, and provide evidence-based surveillance criteria to define infections to nursing staff. The DON indicated that the management company was responsible for policy updates, and there was no form or guide for nurses to use McGreer's criteria for infection identification. Interviews with licensed practical nurses revealed a lack of awareness of any specific criteria or tools to define infections before requesting tests.
Failure to Follow Care Plan for Resident with Choking Risk
Penalty
Summary
The facility failed to adhere to provider orders and care plan interventions for a resident with severely impaired cognition and a diagnosis of dementia. The resident required setup and cleanup assistance with meals and was dependent on others for bed mobility and transfers. According to provider orders, the resident was on a mechanical soft diet due to difficulty swallowing and chewing, and the care plan specified that the resident should eat meals with direct supervision and feeding assistance in the dining room. However, on the observed date, the resident was found lying in bed with the head of the bed elevated only about 30 degrees, slouched down, and with a meal tray on an over-the-bed table. The resident had been eating unsupervised, contrary to the care plan, and was at risk for choking and aspiration. Interviews with staff revealed a lack of awareness and recall regarding the resident's unsupervised meal in bed. A nursing assistant who worked the day shift did not remember the resident eating in bed, and another nearby nursing assistant also had no recollection of the incident. A registered nurse confirmed that the resident was at risk for choking and should not have been eating alone in bed. The director of nursing stated that it was not expected for a known choking risk to be eating in bed unsupervised, highlighting a failure in following the care plan and ensuring the resident's safety.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and obtain informed consent prior to the use of bed rails for a resident who was reviewed for bed rail use. The resident, who had intact cognition and a diagnosis of hip fracture, required moderate assistance with rolling and repositioning. The resident's care plan did not include information related to the use of bed rails, and the medical record lacked an assessment for bed rail alternatives, entrapment risk, or informed consent for bed rail use. During an observation, bed rails were noted to be attached to the head of the bed on both sides. Interviews with facility staff revealed that a Bed Mobility Device Evaluation form should have been completed for all residents prior to the placement of bed rails, which includes evaluating the resident's ability to use the rails, interventions utilized before bed rails, and fall and injury risk. However, the registered nurse confirmed that no assessment or consent forms were present in the resident's chart. The director of nursing stated that it was expected for all staff performing assessments to complete a mobility device assessment and obtain consent before placing bed rails, but the facility's bed rail use policy was not provided.
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What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eveleth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Waterview Pines Llc | 3.5 mi | — | 15 | 0 |
| Essentia Health Virginia Care Cent | 4.5 mi | — | 4 | 0 |
| Cornerstone Villa | 11.3 mi | — | 4 | 0 |
| Essentia Health Northern Pines Medical Center | 15 mi | — | 5 | 0 |
| Heritage Manor | 15.6 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.