Waterview Shores: Fall Care Plan Failures - MN
That gap matters because the care plan is what tells staff what to do. If it isn't in the care plan, there is no guarantee anyone knows to do it.
The Director of Nursing confirmed the sequence to inspectors. After a fall on June 19, 2025, the interdisciplinary team determined a bedside floor mat was the right intervention. The mat did not appear in the resident's care plan until August 28, the same day he fell again. The DON said she added it "as soon as we realized it was not identified in R1's care plan at the time of his fall on 8/28/25." She could not explain why it had been left out for the preceding ten weeks.
The August 28 fall produced its own paperwork failure. Four days earlier, on August 24, the resident had fallen a second time. The team decided then that he should use a soft-touch call light clipped to his right hip. That intervention wasn't added to his care plan until August 29, the day after he fell again.
The DON acknowledged that when the resident fell on August 28, staff would not have known about either the floor mat or the call light. Neither was in the care plan. She was unsure whether the care guide sheets floor staff actually use had been revised to include them.
The facility's own fall prevention policy required care plans to be updated with interventions following any fall. The DON described a process where the floor nurse notifies her after a fall, the two determine an immediate intervention, and the interdisciplinary team reviews incidents each morning. Somewhere in that chain, the documentation step was skipped. Twice.
The facility corrected the care plan on August 29 and educated staff. Inspectors classified the violation as causing actual harm to a small number of residents. The resident had already fallen three times before his paperwork caught up to his needs.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
THE WATERVIEW SHORES LLC in TWO HARBORS, MN was cited for violations during a health inspection on September 11, 2025.
That gap matters because the care plan is what tells staff what to do.
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.