Waterview Shores: Care Plan Failures Led to Injury - MN
The resident, identified in inspection records only as R1, required staff assistance with all of his daily activities. He could not reliably call for help on his own. The facility knew he was a fall risk.
He fell on June 19, 2025. No injuries that time. The interdisciplinary care team determined he needed a floor mat placed beside his bed. Nobody added it to his care plan.
He fell again on August 24, 2025. Still no injuries. The team decided he should also have a soft-touch call light positioned at his right hip, so he could summon staff without getting up. That wasn't added to his care plan either, at least not right away.
Four days later, on August 28, 2025, he fell a third time. This time he was hurt. He sustained a rib injury.
The interim director of nursing, interviewed by inspectors on September 11, 2025, confirmed the sequence plainly. The floor mat intervention decided upon after the June fall was not added to R1's care plan until August 28, the same day as the third fall. The call light intervention decided upon after the August 24 fall was not added until August 29, the day after. The DON stated she was unsure why the floor mat had not been added immediately after the June fall, and acknowledged that staff would not have known about either intervention at the time R1 went down on August 28, because neither one was in the care plan and she was unsure whether the floor staff's care guide sheets had been updated to reflect them.
A nursing assistant identified as NA-D described the interventions staff were supposed to follow: keep R1 near the nurses' station when he was restless or active, use a low bed, place a fall mat beside it, and position the touch pad call light beneath him when he was in bed. NA-D said she learned about the fall and the rib injury after the fact, when the DON and administrator called her to provide education on following resident-specific fall interventions and on what to do if a staff member notices an intervention that had previously been in place is no longer there.
That last part is worth pausing on. Staff were educated, after the injury, on what to do if an intervention goes missing. The intervention in question had never been formally documented in the first place.
The DON described how the process was supposed to work: after a fall, the floor nurse notifies the DON, they discuss root cause and determine an immediate response together. Then the interdisciplinary team meets every morning on business days to go through incident reports and determine appropriate interventions. The DON then revises the care plan and informs staff verbally, so they can pass it along during shift report and update the care sheets they use on the floor.
That process did not happen after the June 19 fall, not completely. The floor mat was decided on. It was not written down where staff could find it. Weeks passed. R1 fell twice more.
Inspectors cited the facility for failing to develop and keep current a comprehensive care plan, a deficiency rated at the level of actual harm.
The facility's corrective actions, implemented starting August 29, included updating R1's care plan with current fall interventions, educating all staff on following care plans and reaching out to the floor nurse or DON with questions, beginning weekly audits to confirm that IDT interventions had been added to care plans, and changing the IDT process to require double-checking that an intervention was documented in both the care plan and the care guide sheets before closing an incident report.
Those changes came after R1's ribs were broken.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Waterview Shores LLC from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
The Waterview Shores LLC in TWO HARBORS, MN was cited for violations during a health inspection on September 11, 2025.
The resident, identified in inspection records only as R1, required staff assistance with all of his daily activities.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.