The violation affected a small number of residents.
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The collagen powders were not in locked compartments.
The facility did not initiate this review.
The November 2025 inspection of The Waterview Woods LLC resulted in 13 separate deficiency citations.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on November 20, 2025, responding to a complaint.
No actual harm was documented during the inspection.
Inspectors classified the harm level as minimal or potential, meaning they found no evidence that residents had been seriously hurt yet.
The citation came through a complaint investigation, meaning someone had already raised a concern before inspectors ever walked through the door.
The finding came from a complaint inspection conducted November 20, 2025.
Resident 3 went to the dining room for lunch.
The error compounded with each one.
The staffing shortage centered on what inspectors described as the traditional evening shift, covering 6 p.m.