Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodland Terrace during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Dietary staff failed to follow proper hand hygiene and food handling procedures, including handling food with bare hands after touching contaminated surfaces and not washing hands as required. The kitchen floor remained dirty over several days, and staff did not use gloves or utensils as directed by facility policy, leading to unsanitary conditions during meal preparation and service.
Two residents received incorrect medication dosages: one received a higher dose of Atropine than ordered, and another was given a calcium and vitamin D supplement with a lower vitamin D dose than prescribed due to a pharmacy error. These incidents resulted in a medication error rate above 5%, with staff failing to follow established medication administration protocols.
Surveyors identified expired and improperly labeled medications on a medication cart, including melatonin, docusate sodium, Latanoprost eye drops for two residents, and insulin pens lacking required labeling. Staff interviews revealed inconsistent medication cart audit practices and failure to follow facility policy for removing expired medications.
Staff did not consistently wear required PPE during high-contact care for a resident on Enhanced Barrier Precautions with a chronic indwelling urinary catheter and recent UTI, and failed to prevent the resident’s urinary drainage bag and tubing from coming into contact with the floor, contrary to facility policy and infection control standards.
A resident was transferred to the hospital on two occasions without documentation that she or her POA was notified of the facility's Bed Hold policy, as required by facility policy. Staff confirmed that the Bed Hold process was not followed, and there was no evidence of notification or documentation in the EHR.
A resident with a history of benign prostatic hyperplasia, obstructive uropathy, and renal insufficiency was not accurately coded for an indwelling catheter on the MDS assessment, despite physician orders, care plan documentation, and staff interviews confirming ongoing catheter use. The MDS Coordinator acknowledged the omission after review of the EHR and staff input.
A resident with an unstageable pressure ulcer on the heel did not receive consistent weekly assessments and interventions as required by the facility's wound treatment policy. Despite initial treatments and documentation of a deep tissue injury, the facility failed to provide weekly measurements and assessments, leading to a stalled and unchanged condition. The DON confirmed the deficiency in meeting the standards for pressure ulcer care.
A facility failed to follow infection control protocols during medication administration for two residents. An RN did not perform hand hygiene before or after insulin administration and failed to wear gloves while administering a nasal spray, contrary to facility policy. Interviews confirmed awareness of proper procedures.
The facility did not have the required members, specifically the Infection Preventionist Nurse, present at two of the four quarterly Quality Assessment and Assurance (QAA) meetings. This was confirmed through sign-in sheets and interviews with the Co-Directors of Nursing and the Administrator. The facility's Quality Assurance and Performance Improvement Plan specified the necessary members for the QAA Committee.
A resident with severely impaired cognition and a history of falls experienced an unwitnessed fall resulting in a fractured femur due to staff failing to position the bed in the low position before leaving the resident unattended. The facility's investigation confirmed that the bed was left in the highest position, contributing to the fall and injury.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Sanitary Food Handling and Kitchen Conditions
Penalty
Summary
Staff in the dietary department failed to maintain sanitary conditions and adhere to professional food safety standards during meal preparation and service. Observations revealed that a dietary staff member handled hamburger buns and food items with bare hands after touching her face, adjusting her clothing, and glasses, without performing proper hand hygiene. The same staff member washed her hands for only five seconds, contrary to the facility's policy requiring a 20-second wash, and then used tongs to handle food. Additionally, the kitchen floor on the second floor was repeatedly observed to be dirty, with dried food and a dirty bowl remaining in the same spot over multiple days, despite policies and staff statements indicating that housekeeping should clean these areas after each meal. Another dietary staff member was observed preparing pureed meals for residents on physician-ordered pureed diets without performing hand hygiene before or between tasks. This staff member used a rubber spatula that had fallen into ground meat, handled equipment and food items with bare hands, and failed to wash hands or change gloves as required by facility policy. The staff member also placed utensils directly on unclean counters and did not use barriers as required, further increasing the risk of cross-contamination during food preparation. Interviews with dietary and housekeeping managers confirmed that staff are expected to use gloves or utensils when handling ready-to-eat foods and to wash hands after any activity that could contaminate them. Facility policies reviewed directed staff to wash hands for 20 seconds and to use single-use gloves or utensils for food handling. Despite these policies, staff actions did not align with established procedures, resulting in unsanitary food handling and kitchen conditions.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to physician orders, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold. In one instance, a resident with severe cognitive impairment and a diagnosis of oropharyngeal cancer was ordered to receive Atropine Sulfate Ophthalmic Solution 0.01%, one drop by mouth as needed for secretions, up to four times daily. However, a Certified Medication Aide administered three drops instead of the prescribed one drop. Staff interviews confirmed that the expectation is to follow the five rights of medication administration, but this was not adhered to during the observed medication pass. In another case, a resident with intact cognition and a history of fracture and non-Alzheimer's dementia was prescribed Calcium 600 mg plus Vitamin D 800 units, to be taken twice daily. Instead, the resident received Calcium 600 mg with Vitamin D3 400 units due to a pharmacy dispensing error, and this incorrect dosage was administered for multiple doses. The facility's double-check system for medication orders and pharmacy deliveries was not effectively implemented, as the error was not identified before administration. The facility's medication administration policy did not clearly define acceptable standards for personnel to follow, contributing to these errors.
Expired and Improperly Labeled Medications Found on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to properly store and remove expired medications from one of three medication carts inspected. During the inspection of the Evergreen Arbor medication cart, several expired medications were discovered, including bottles of melatonin, docusate sodium, and Latanoprost eye drops for two residents, all past their expiration dates as indicated by manufacturer guidelines and facility policy. Additionally, a Lantus Solostar KwikPen was found without an expiration date written on the packaging or pen label, and an Insulin Lispro Injection KwikPen was present with a broken seal, lacking both a resident name and an open date. Interviews with staff revealed inconsistencies in medication cart audit frequency and procedures for labeling and removing expired medications. While some staff believed audits occurred quarterly, others stated they were performed monthly, with the last inspection of the cart occurring over a month prior to the survey. Facility policy required that no discontinued, outdated, or deteriorated medications be available for use, and that all such medications be destroyed, but these procedures were not consistently followed, resulting in expired and improperly labeled medications remaining accessible on the cart.
Failure to Follow Enhanced Barrier Precautions and Prevent Cross-Contamination
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols for a resident on CDC Enhanced Barrier Precautions (EBP) who had a chronic indwelling urinary catheter and a recent history of urinary tract infection with multi-drug-resistant organisms. During high-contact care activities, such as transferring the resident from bed to wheelchair, a Certified Nursing Assistant did not wear the required isolation gown and gloves, despite signage and facility policy indicating the necessity of personal protective equipment (PPE) for such tasks. Multiple staff interviews confirmed that PPE should be used during high-contact care and catheter care, but this was not consistently practiced. Additionally, the resident’s urinary drainage bag and tubing were observed in direct contact with the floor on more than one occasion, both in the resident’s room and in the dining area. Staff did not address the contamination risk, and it was noted that the privacy bag used to contain the catheter sometimes failed to keep the drainage bag off the floor as intended. Facility policy required that urinary drainage bags be covered and kept off the floor at all times, but this was not followed, resulting in a failure to prevent cross-contamination.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide required notification of its Bed Hold policy to a resident or her Power of Attorney (POA) during two separate hospitalizations. Record review showed that the resident was discharged to the hospital on two occasions, but there was no documentation in the Electronic Health Record (EHR) or progress notes indicating that either the resident or her POA was informed about the facility's Bed Hold policy. Staff interview confirmed that the Bed Hold process was not followed for these transfers, and the facility's policy requires that notice be given to the resident or representative upon transfer, with follow-up contact and documentation within 24 hours. The facility census at the time was 86 residents.
Failure to Accurately Code Indwelling Catheter on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment regarding the presence of an indwelling catheter during the required look-back period. The MDS, completed and signed by the MDS Coordinator, did not indicate the presence of an indwelling catheter, external catheter, ostomy, or intermittent catheterization, despite the resident having physician orders for catheter care, documentation in the care plan, and multiple staff interviews confirming the ongoing use of a Foley catheter. The resident had documented diagnoses of benign prostatic hyperplasia, obstructive uropathy, and renal insufficiency, all of which are relevant to the use of a catheter. Electronic Health Record (EHR) review showed active orders for catheter changes, bag changes, irrigation, and output monitoring, all of which were reviewed and signed by the physician. Staff interviews with CNAs and an RN consistently confirmed the resident had a Foley catheter in place, with no indication it had been removed. The MDS Coordinator acknowledged responsibility for the assessment and admitted to failing to code the indwelling catheter, despite following the RAI manual. The deficiency was identified through review of the EHR, care plan, and staff interviews, which all contradicted the information recorded in the MDS.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide consistent weekly assessments and interventions for a resident with an unstageable pressure ulcer on her heel. The resident, identified as having a deep tissue pressure injury (DTPI), did not receive the required weekly measurements and documentation of the wound's condition. Despite the presence of a wound treatment policy that mandates accurate documentation of wound assessments and treatments, the facility did not adhere to these guidelines for this resident. The resident's medical records indicated that the pressure ulcer was initially noted as a painful area on the heel, which was treated with cleansing, antibiotic ointment, and elevation of the feet. Subsequent progress notes documented the presence of a deep tissue injury, with treatments including skin prep and the use of moon boots and an air mattress. However, the wound evaluations showed inconsistent measurements over several weeks, and the area was described as stalled and unchanged, with no weekly assessments or measurements documented. The Director of Nursing (DON) acknowledged that the pressure ulcer was not healed and confirmed the lack of weekly measurements and assessments. The facility's wound treatment policy requires documentation of wound assessments upon admission, weekly, and as needed, including details such as wound type, stage, measurements, and characteristics. Despite these requirements, the facility did not meet the standards for assessing and intervening in the resident's pressure ulcer care.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration for two residents. During an observation, a Registered Nurse (RN) did not perform hand hygiene before or after administering insulin to a resident. The RN gathered supplies, prepared the insulin pen, and administered the insulin without washing hands at any point during the process. This oversight was noted during a survey, highlighting a lapse in following the facility's infection control protocols. In another instance, the same RN performed hand hygiene before gathering supplies for another resident's medication administration but failed to wear gloves while administering a nasal spray. The RN completed the task and performed hand hygiene afterward but did not adhere to the facility's policy requiring gloves for procedures involving potential contact with body fluids. Interviews with the RN and the Co-Director of Nursing confirmed awareness of the proper procedures, indicating a deviation from established guidelines.
Inadequate QAA Meeting Attendance
Penalty
Summary
The facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings, which are essential for identifying necessary quality assessment and assurance activities. The facility, with a census of 85 residents, did not have the Infection Preventionist Nurse present at two of the four quarterly QAA meetings. This was confirmed through a review of the facility's QAA sign-in sheets and interviews with the Co-Directors of Nursing and the Administrator. The facility's Quality Assurance and Performance Improvement Plan indicated that the QAA Committee should include the Director of Nursing, Medical Director, Assistant Director of Nursing, Infection Preventionist Nurse, Administrator, Staff Development Nurse, and Skilled Registered Nurse Coordinator.
Failure to Follow Safety Interventions Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to follow safety interventions for a resident with severely impaired cognition and a history of falls. On the specified date, staff did not position the resident's bed in the low position before leaving the resident unattended. This oversight led to the resident experiencing an unwitnessed fall from the bed, resulting in a fracture of the right femur. The resident's care plan included multiple safety interventions, such as intentional rounds and ensuring the bed was in a safe position, which were not adhered to at the time of the incident. The incident report and staff interviews revealed that the bed was left in the highest position, and the call light was not activated when the fall occurred. Staff statements and camera footage confirmed that the bed was not lowered after care was provided, and the resident was left unattended. The resident was found on the floor with a distorted right leg, indicating a fracture, and was subsequently sent to the emergency room for treatment. The facility's investigation concluded that the failure to lower the bed contributed to the fall and injury. The administrator confirmed that the bed should have been in the low position when the resident was unattended. The facility was unable to provide a policy or protocol regarding the positioning of beds when residents are in bed and unattended, highlighting a gap in their safety procedures.
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What surveyors actually found near you
We read the 136 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Waverly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shell Rock Senior Living | 4.2 mi | ★★★★★ | 13 | 0 |
| Denver Sunset Home | 8.9 mi | ★★★★★ | 2 | 0 |
| Clarksville Skilled Nursing & Rehab Center | 9.9 mi | ★★★★★ | 2 | 0 |
| Tripoli Nursing & Rehab | 12.8 mi | ★★★★★ | 0 | 0 |
| Pillar Of Cedar Valley | 12.8 mi | ★★★★★ | 13 | 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 July 2026) and official state health department websites.