The Waterview Shores Llc
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
all staff education on following care plan interventions for falls and alerting management if you are not seeing an intervention anymore that had been previously used.On 9/11/25 at 9:44 a.m., NA-D stated Resident R1 was at risk for falls and staff were directed to keep him near nurse's station if he was restless or active, and if Resident R1 was in bed he would require a low bed, fall mat which he has had quite a while, and a touch pad call light underneath him too. Further, NA-D stated she was aware Resident R1 had a fall and sustained a rib injury.
Following Resident R1's fall, NA-D stated the DON, and administrator called her and provided education related to resident specific fall interventions and what to do if staff notice an intervention was missing.On 9/11/25 at 11:51 a.m., interim director of nursing (DON) stated Resident R1's cognition was impaired and Resident R1 required staff assistance with all ADLs. DON stated Resident R1 was at risk for falls and interventions to prevent falls included: toileting every 2-3 hours, concave mattress, room and floor clean, floor mat next to bed, two signs posted in his room to use call light for assistance, and soft touch call light to the right hip. Further, DON stated Resident R1 had
a fall on 6/19/25, with no injuries, and confirmed interdisciplinary team (IDT) determined a fall mat at Resident R1's bedside was an appropriate intervention; however, DON confirmed the floor mat was not added to Resident R1's care plan until 8/28/25. DON was unsure why the intervention was not added to Resident R1's care plan immediately, but stated DON added the intervention as soon as we realized it was not identified in Resident R1's care plan at the time of his fall on 8/28/25. DON stated Resident R1 had another fall that occurred on 8/24/25, with no injuries, and IDT determined an appropriate intervention would be Resident R1 to use a soft touch call light; however, Resident R1's care plan was not updated until 8/29/25. DON stated all staff would not have been aware of those two interventions, the floor mat and the call light, at the time of Resident R1's fall on 8/28/25, since they were not identified in Resident R1's care plan and DON was unsure if the staff's care guide sheets were revised to include those at the time. DON stated following a fall, the floor nurse would notify the DON, and the DON and nurse would discuss root cause and determine an immediate intervention together. The DON stated then the IDT would meet every morning on business days and go through the risk management/incident reports, which
the IDT then would determine an appropriate intervention, and DON would revise the care plan as well as inform the staff verbally to pass on in report and add to the care sheets the floor staff utilize. Review of facility policy titled Care Planning revised 11/24, indicated the care plan would be used in developing the resident's daily care routines and utilized by staff personnel for the purposes of providing care or services to the resident. The plan of care would be utilized to provide care to the resident. The care plan was to be modified and updated as the condition and care needs of the resident changes.Review of facility policy titled Fall Prevention and Management revised 2/24, indicate following a fall nursing staff would complete
an incident review and analysis. The IDT would review falls daily at morning meeting. When a resident falls,
the following information should be recorded in the resident's medical record: interventions, first aid, or treatment administered, and appropriate interventions taken to prevent future falls. Further, follow up included care plans would be updated to reflect fall interventions.The facility implemented the following corrective action on 8/29/25 and this is being issued in past noncompliance. -Resident R1's care plan was updated with current fall interventions,-All staff were educated on revisions and following care plans, if staff had questions or clarifications regarding interventions reach out to the floor nurse or DON-Audits weekly to ensure IDT interventions have been implemented and are in care plan-IDT process change to double check
the intervention was added to the care plan and the care guide sheets prior to closing the risk management/incident report
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The Waterview Shores LLC in TWO HARBORS, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TWO HARBORS, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Waterview Shores LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.