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 Aperion Care Summerfield during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple diagnoses had conflicting documentation regarding code status, with the physician order indicating full code while the POST form and care plan indicated DNR. Staff interviews confirmed the inconsistency, and facility policy requiring alignment of physician orders with advanced directives was not followed.
A resident with Huntington's disease, dysphagia, and nutritional deficiency was incorrectly coded as having a feeding tube on the MDS assessment, despite medical records and interviews confirming no feeding tube was ever used. The error was attributed to a coding mistake during the assessment process.
A resident with cognitive impairment and complex medical needs did not have documented quarterly care plan meetings or evidence of being notified and offered to attend, despite facility policy requiring such meetings. Staff interviews confirmed that while some meetings occurred, they did not address all care needs or follow required documentation practices.
Surveyors found that water temperatures in the dining room kitchen sink and a common restroom were significantly above the facility's policy range, with readings of 143 and 135.5 degrees Fahrenheit. Staff had difficulty adjusting the water during handwashing, and the common restroom door was found unlocked, allowing potential access. Water temperatures in resident rooms were within acceptable limits, but the facility failed to ensure safe water temperatures in all accessible areas.
Dietary staff failed to follow proper hand hygiene protocols by washing hands for less than the required time and turning off faucets with bare hands before serving food or assisting a resident, contrary to facility policy.
The facility failed to provide RN coverage for 8 hours per day, 7 days per week, for 7 out of 28 days reviewed. The DON was scheduled as the RN from Monday to Friday, but no RN was scheduled for the weekends. The Administrator indicated that the DON was available for calls during the weekends. This deficiency had the potential to affect all 40 residents in the facility.
A facility failed to ensure a call light was within reach for a resident with severe cognitive impairment and physical limitations. Over several days, the call light was repeatedly found on the floor under storage containers, despite the care plan and facility policy requiring it to be accessible.
The facility failed to ensure proper food safety and hygiene practices in the kitchen, including staff not wearing hairnets, improper hand hygiene, undated food items, dented cans in storage, and food stored directly on the floor. These deficiencies had the potential to affect all 40 residents receiving food from the kitchen.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently documented across the physician order, care plan, and POST (Physician Orders for Scope of Treatment) form. Record review revealed that the physician order indicated the resident was a full code, while the most recent POST form and care plan documented the resident as Do Not Resuscitate (DNR). The resident had a history of Huntington's Disease, anxiety, and dysphagia, and was noted to be cognitively impaired according to a recent MDS assessment. Interviews with facility staff confirmed the inconsistency, with the Administrator acknowledging that the POST form was correct and the physician order was incorrect. An LPN stated that the resident's code status changed frequently and updates were recorded in the medical record, but did not address the discrepancy between documents. Facility policy required that physician orders be specific and address each advanced directive, but this was not followed in the resident's case.
Inaccurate MDS Assessment Due to Feeding Tube Coding Error
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident. During an interview, the resident denied ever having a feeding tube, and a review of her medical record confirmed there was no history of feeding tube use. The resident's diagnoses included Huntington's disease, dysphagia, and nutritional deficiency. Her physician's order specified a regular diet with mechanical soft, thick liquids, and her care plan addressed nutritional concerns related to her condition, but did not mention a feeding tube. Despite this, the quarterly MDS assessment incorrectly indicated that the resident had a feeding tube. Interviews with the MDS Coordinator and the Administrator confirmed that this was a coding error, likely due to the wrong box being marked on the assessment. The error was identified during the survey process, and it was acknowledged that the MDS assessment needed to be modified to reflect the resident's actual status.
Failure to Complete and Document Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that quarterly care plan meetings addressing the specific needs of a resident were completed as required. Record review revealed that a resident with diagnoses including Huntington's Disease and epilepsy, who was cognitively impaired, did not have documentation of quarterly care plan meetings or evidence that the resident was notified and offered the opportunity to attend such meetings. Although the comprehensive care plan was reviewed and updated, there was no record of quarterly interdisciplinary team meetings or invitations extended to the resident or their representative. Interviews with the Social Services Director and the Administrator confirmed that while meetings with the resident did occur, these were focused on specific issues such as the resident's desire for more freedom and intimacy, rather than comprehensive care planning. The Administrator acknowledged that documentation did not reflect a specific care plan meeting addressing all of the resident's needs, as required by facility policy. The lack of documentation and formal quarterly care plan meetings constituted the deficiency.
Unsafe Water Temperatures in Common and Staff Areas
Penalty
Summary
The facility failed to maintain safe water temperatures in several areas accessible to staff and potentially to residents and visitors. During multiple observations, water temperatures at the main dining room kitchen sink and the common restroom on the south hall were found to be significantly above the facility's policy range, measuring 143 degrees and 135.5 degrees Fahrenheit, respectively. Staff were observed having difficulty adjusting the water temperature during handwashing, and the common restroom door was found unlocked on two occasions, allowing potential access. In contrast, water temperatures in resident rooms were within acceptable parameters according to facility logs and direct observation. The Administrator confirmed that the employee restroom water was connected to the main kitchen supply and was unaware that the common restroom door had been left unlocked, suggesting a visitor may have left it open. The Administrator also stated that the elevated water temperature was intended for preparing hot drinks and did not consider it too hot for employees. The facility's policy specified that water temperatures at sinks and showers should be between 100-120 degrees Fahrenheit to prevent hazards, but this standard was not met in the areas observed.
Failure to Ensure Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during meal service, as observed in multiple instances involving dietary aides. On several occasions, dietary staff washed their hands for less than the required 20 seconds, turned off the faucet with their bare hands instead of using a paper towel, and subsequently proceeded to serve food or assist residents without following correct handwashing technique. These actions were directly observed during dining times, where staff either adjusted residents in their wheelchairs or handled food trays immediately after improper handwashing. Interviews with facility staff confirmed awareness of the improper hand hygiene practices, with acknowledgment that the correct technique was not followed during meal service. The facility's handwashing policy requires washing hands for 20 seconds, cleaning under nails and between fingers, rinsing without touching the faucet, and using a paper towel to turn off the faucet. However, the observed practices did not align with these standards, leading to the identified deficiency.
Failure to Provide RN Coverage 8 Hours Per Day, 7 Days Per Week
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 hours per day, 7 days per week, for 7 out of 28 days reviewed. Specifically, the Director of Nursing (DON) was scheduled as the RN from Monday to Friday, but no RN was scheduled for the weekends of 4/6/24, 4/7/24, 4/12/24, 4/13/24, 4/19/24, 4/20/24, or 4/28/24. The Administrator indicated that the DON was available for calls during the weekends. This deficiency had the potential to affect all 40 residents in the facility. The facility's policy, dated 2001, stated that adequate staffing, including licensed registered nursing staff, should be maintained on each shift to ensure residents' needs and services are met.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a call light was kept within reach for a resident with severe cognitive impairment and multiple physical limitations. Over several days, the resident was observed sitting on his bed with the call light consistently found on the floor underneath two plastic storage containers, making it inaccessible. This was observed on three separate occasions by surveyors, and the Director of Nursing confirmed the call light should be within the resident's reach. The resident, who was admitted with diagnoses including Huntington's disease, unsteadiness of feet, reduced mobility, and repeated falls, required supervision or assistance for activities of daily living. The care plan specifically indicated that the call light should be kept within reach to mitigate the risk of falls. Despite this, the call light was repeatedly found out of reach, indicating a failure to adhere to the care plan and facility policy, which mandates that call lights be accessible to residents at all times.
Improper Food Safety and Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a tour with the Dietary Manager (DM). The DM did not wear a hairnet and failed to wash her hands before handling food items. Multiple food items in the kitchen freezers were found undated, including bags of biscuits, French fries, lemon pies, sausage tubes, waffles, and various other items. Additionally, the dry storage area contained dented cans of tomato sauce and a large box of ice cream cones stored directly on the floor without a barrier. The DM also demonstrated improper hand hygiene by wiping her brow with her bare hand, touching her hair, and then handling food items without washing her hands properly. She also turned off the water faucet with her bare hand and wiped her wet hands on her pants due to the absence of paper towels in the dispenser. The Administrator (ADM) confirmed that staff are required to wear hairnets, wash their hands properly, and ensure all food items are labeled and dated. The ADM also stated that food items should not be stored directly on the floor and dented cans should be discarded. The facility's policies on handwashing and food storage were provided, which outlined the proper procedures for hand hygiene and food storage, including the requirement to label and date all food items, discard dented cans, and store food at least six inches above the floor. These deficiencies had the potential to affect all 40 residents who received food from the kitchen.
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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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Nursing homes near Cloverdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Greencastle, The | 8.1 mi | ★★★★★ | 12 | 0 |
| Hickory Creek At Sunset | 9.2 mi | ★★★★★ | 7 | 0 |
| Mill Pond Health Campus | 9.3 mi | ★★★★★ | 10 | 0 |
| Asbury Towers Health Care Center | 9.9 mi | ★★★★★ | 10 | 0 |
| Owen Valley Rehabilitation And Healthcare Center | 15.3 mi | ★★★★★ | 5 | 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.