Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Apple Ridge Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, paranoid schizophrenia, bipolar disorder, and mood disorder had phone use restricted to limited, supervised calls because of concerns about calls to lawyers and an outside advocate. The record showed changing limits on call frequency and duration, monitoring of conversations, and restrictions on who could be contacted, but there was no physician order, clinical assessment, or care plan justification supporting the limits. The resident reported feeling watched and upset, and staff confirmed the restrictions were based on guardian direction rather than clinical need.
Delayed UTI Identification and Physician Notification Failure: A resident with autism, bipolar disorder, and severe ID had dysuria and cloudy urine, but the UA specimen was not collected and the physician was not notified when the resident continued to decline with dizziness, nausea, poor appetite, pallor, clammy skin, weight loss, and malaise. The resident was later sent to the ER and diagnosed with a UTI; ciprofloxacin was started without culture and sensitivity results, and the antibiotic was later changed after the culture showed it was not effective.
Two residents with behavioral health diagnoses were left unsupervised on a locked unit when a CMT left to retrieve medication records during an internet outage. In the absence of staff, a verbal and physical altercation occurred between the residents over delayed medication administration. Staff interviews confirmed that the unit was left unattended, and facility leadership acknowledged that supervision should have been maintained at all times.
Two residents with psychiatric diagnoses engaged in a verbal and physical altercation when the behavioral health locked unit was left unsupervised by staff. The incident escalated after one resident became upset about delayed medication administration due to an internet outage, leading to yelling and one resident striking the other. Multiple interviews confirmed that no staff were present on the unit at the time, and the facility's policy requiring active protection from abuse was not followed.
Residents without personal phones were required to use the nurses' office phone, where staff presence and the phone's location prevented private conversations. Several residents with mental health and developmental diagnoses reported being unable to make private calls, and staff confirmed that privacy was only offered if specifically requested, with supervision maintained by keeping the office door ajar. The facility had previously provided a portable phone for private use, but this was discontinued, leaving no alternative for residents needing privacy.
A facility failed to protect resident confidentiality when a maintenance director, unaware of HIPAA regulations, disposed of 136 residents' medical records in a public dumpster. The records, labeled with names and years, were accessible until discovered. Other staff, including an LPN and a housekeeper, were aware of proper PHI disposal procedures, but these were not followed in this incident.
The facility failed to maintain a comprehensive infection prevention and control program, particularly for Legionella and TB testing. The Legionella Water Management Plan was incomplete, and several residents did not receive the required two-step TB skin test upon admission. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds or indwelling medical devices, with staff lacking awareness and training on EBP requirements.
The facility failed to provide a comprehensive activities program for residents, affecting their physical, mental, and psychosocial well-being. A resident expressed dissatisfaction with the lack of weekend activities, while another noted that behavior issues among some residents limited their participation. Observations confirmed the absence of activities, and staff interviews revealed that activities were not conducted regularly, especially on weekends, due to the Activities Director's absence.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's specific needs and triggers. Despite having a care plan, staff lacked recent training on PTSD, contributing to inadequate care. The facility's policy required training, but documentation of recent sessions was unavailable.
A facility failed to accurately document narcotic pain medication for several residents, leading to discrepancies between the Medication Administration Record (MAR) and narcotic count logs. Interviews revealed that narcotic counts were not consistently conducted at shift changes, and there were missing signatures on count sheets. Staff admitted to not always counting liquid narcotics, assuming they were full and unopened. The Director of Nursing acknowledged responsibility for ensuring accurate narcotic counts and documentation.
The facility failed to document and provide education on pneumonia vaccinations for five residents upon admission, as required by their policy. Interviews with staff revealed uncertainty about who was responsible for ensuring this education, contributing to the deficiency.
The facility failed to provide and document COVID-19 vaccine education for five residents and five staff members. Interviews revealed confusion among staff about responsibility for vaccine education, with the ADON assuming the DON was responsible and the Regional Nurse believing it was unnecessary post-Public Health Emergency. The DON was unsure if education was provided, indicating a systemic issue in managing COVID-19 vaccination protocols.
A facility failed to provide written notification of a hospital transfer to a resident and the Ombudsman. The resident, who had moderate cognitive impairment, was sent to the hospital after a fall. Interviews revealed that the resident was unaware of any written notification, and the DON confirmed that notifications should have been issued to both the resident and the Ombudsman.
A facility failed to provide a written bed hold policy notification to a resident with moderate cognitive impairment who was transferred to the hospital after a fall. The resident was unaware of receiving such notification, and the LPN confirmed the requirement for written provision. The DON acknowledged the oversight.
A facility failed to complete an annual MDS for a resident, as required by federal guidelines. The MDS Coordinator, who took over after the due date, noted that the previous program lacked notifications for overdue assessments. The facility switched to a new system that provided due dates, but this change occurred after the MDS was already overdue. The DON confirmed the need for timely MDS completion.
A facility failed to complete MDS assessments for a resident at the required intervals. The resident's third quarterly MDS was completed one month late, and the annual MDS was not completed. The MDS Coordinator noted that the previous software did not provide overdue notifications, contributing to the oversight. The facility switched to a new program, but the resident's MDS was already overdue.
A resident with dysphagia and gastrostomy status was not accurately assessed for dental issues, despite having broken teeth and reporting daily pain. The MDS did not document these concerns, and interviews revealed that the MDS nurse and DON were unaware of the resident's dental condition, indicating a failure in the assessment process.
The facility failed to personalize care plans for two residents, leading to deficiencies in communication and dental care. One resident's communication care plan lacked specific interventions despite their preference for Spanish and moderate cognitive impairment. Staff relied on family for translation and used basic Spanish and gestures. Another resident with dysphagia and broken teeth had no dental care plan, and staff were unaware of their dental issues, despite the resident reporting daily pain. These deficiencies highlight inadequate care planning.
The facility failed to ensure the activities program was directed by a qualified professional. The current Activities Director (AD) lacked the necessary qualifications, including two years of college, relevant experience, or state-approved training. The Administrator acknowledged the deficiency, and an attempt to interview the AD was unsuccessful. The facility's policy for the AD was requested but not provided.
A resident with dysphagia and broken teeth did not receive necessary dental care, despite expressing daily pain. The facility staff, including the SSD, LPN, CNAs, and DON, were unaware of the resident's dental issues, and the resident was not seen by the dentist during the last visit. There was no documentation of a dental consent form being provided upon admission.
The facility did not post complete daily nurse staffing information, omitting total actual hours worked for RNs, LPNs, CMTs, CNAs, and NAs. Observations showed missing data on staffing sheets near the nurse's station and no postings in the Behavioral Unit. Staff interviews confirmed the incomplete postings.
A resident with impaired cognition was injured in a dining room altercation when another resident, known for verbal symptoms, hit them on the head with a ringed hand. The incident was triggered by the victim flipping another resident's hat. No staff witnessed the event, and the injury was discovered by a CNA during a shower. The aggressor admitted to the inappropriate behavior.
Unjustified Restrictions on Resident Phone Communication
Penalty
Summary
The facility failed to ensure a resident could exercise the right to private and unrestricted communication when telephone use was restricted without documented clinical justification, a physician order, or a care plan intervention supporting the limits. The resident had diagnoses including schizoaffective disorder, paranoid schizophrenia, bipolar disorder, mood disorder, and a manic episode, but the quarterly MDS indicated the resident was cognitively intact. The record showed that facility and guardian-related communications led to limits on who the resident could call, how many calls could be made, how long calls could last, and whether calls had to be supervised. The resident’s record contained multiple emails from the public administrator and facility staff directing that calls be limited because the resident had been contacting lawyers and an outside advocate. The restrictions included one call per day, later three calls per day, supervision of calls by staff, and limits on calling certain people, including the advocate and random lawyers. The care plan reflected these restrictions and noted the resident was not allowed to talk to the advocate, could receive calls from the court-appointed lawyer, and could call the public administrator only under certain conditions. The record also showed staff were told not to give the resident mail from the resident’s mother. During interview, the resident stated the phone restrictions were imposed because of calls to lawyers, that calls were limited to three per day for 15 minutes, and that staff monitored calls by listening outside the office. The resident said unanswered calls still counted against the limit and incoming calls could count as two calls, and described feeling watched and upset by the restrictions. Staff interviews confirmed the resident had phone restrictions, that calls were to be monitored, and that the restrictions were based on guardian direction and concerns about the advocate, while the public administrator stated there had been no physician involvement and no less restrictive measures attempted before the restrictions were put in place.
Delayed UTI Identification and Failure to Report Change in Condition
Penalty
Summary
The facility failed to ensure one resident received appropriate and timely identification and treatment of a UTI and failed to report changes in the resident’s condition to the physician. The resident had diagnoses including autistic disorder, bipolar disorder, and severe intellectual disabilities, and was being monitored after starting Risperdal and Lithium. On 03/08/26, the physician was contacted because the resident had pain during urination and cloudy urine, and an order was obtained for a UA. The laboratory later reported that the specimen was never received because it was not collected, and the facility was advised to collect a sample on the next routine lab day. After the UA order, the resident continued to have symptoms and changes in condition over the following days. The resident reported not feeling well, dizziness, intermittent nausea, sweats, chills, congestion, pale skin, clammy skin, poor appetite, generalized body aches, fatigue, dizziness with ambulation, bronchial congestion, refusal of meals and snacks, poor sleep, lightheadedness, a 17-pound weight loss, and general malaise. Facility documentation showed supportive measures such as encouraging fluids and rest and giving Tylenol, but the physician was not contacted during this period despite the ongoing changes in condition. The physician was not notified until 03/23/26, when a call was placed and new orders were received for a chest x-ray and Zofran. On 03/26/26, the physician ordered ciprofloxacin and trazodone, but there was no culture and sensitivity available from the lab at that time. The resident was sent to the ER later that day and was diagnosed with a UTI. The resident returned to the facility that evening and started ciprofloxacin, but the hospital culture later showed the organism was susceptible to penicillin and other alternate first-generation antibiotics, not ciprofloxacin. The facility later received the culture results and the physician ordered Keflex after being notified that the current antibiotic therapy was not effective.
Failure to Maintain Supervision on Behavioral Health Unit Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate staffing coverage and supervision on the secure behavioral locked unit, resulting in an altercation between two residents. On the evening in question, a Certified Medication Technician (CMT) left the behavioral unit unsupervised to retrieve printed Medication Administration Records (MARs) due to an internet outage, leaving no staff present on the unit. During this period, two residents engaged in a verbal and physical altercation in the hallway, with one resident striking the other in the upper arm after a dispute over delayed medication administration. The residents involved had significant behavioral health diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. One resident was moderately cognitively impaired, while the other was cognitively intact but had a history of agitation when routines or medication schedules were disrupted. The incident occurred after one resident became upset about not receiving medication on time, leading to a confrontation and subsequent physical contact. Interviews with staff and residents confirmed that the behavioral unit was left without staff supervision at the time of the incident. Multiple staff members, including the CMT, LPNs, CNAs, the Administrator, and the DON, acknowledged that the behavioral unit should never be left unattended and that at least one staff member should always be present. The facility was unable to provide a staffing policy at the time of the survey exit.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to prevent verbal and physical abuse between two residents on the behavioral health locked unit. On the evening of 12/26/25, two residents with significant psychiatric diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression, engaged in a verbal and physical altercation. The incident occurred after one resident became upset about not receiving medication due to a facility internet outage, which delayed the medication pass. The two residents exchanged words, escalated to yelling, and then one resident struck the other in the upper arm. At the time of the incident, there were no staff members present on the locked behavioral unit. The Certified Medication Technician (CMT) assigned to the unit had left to print medication administration records necessary for the medication pass, as the internet was down. Multiple resident interviews confirmed that staff were not present during the altercation, and one resident had to bang on the locked doors to alert staff to the fight. Staff interviews corroborated that the unit was unsupervised during the event, and the administrator acknowledged that staff supervision was expected at all times on the unit. The facility's own Abuse and Neglect Policy states that residents have the right to be free from abuse and that the facility will actively protect residents from such incidents. The lack of staff supervision on the locked behavioral unit directly contributed to the occurrence of resident-to-resident abuse, as there was no immediate intervention or oversight to prevent or de-escalate the situation.
Failure to Provide Private Telephone Access for Residents
Penalty
Summary
The facility failed to ensure that residents on the locked unit had the opportunity to make and receive phone calls without being overheard, as required by their own policy. Residents who did not possess their own phones were required to use the telephone located in the nurses' office, where privacy could not be guaranteed. Staff were typically present in the office during resident calls, and the phone's location and short cord length further limited privacy. Residents reported that staff rarely offered privacy, and even when requested, staff would leave the door ajar to monitor the resident, allowing conversations to be overheard in the hallway. Multiple residents on the locked unit, including individuals with schizoaffective disorder, ADHD, and autistic disorder, expressed dissatisfaction with the lack of privacy during phone calls. These residents indicated that they would prefer to have private conversations but were not provided with a means to do so. The facility previously had a portable phone that allowed residents to make private calls, but this was discontinued about a year prior when a new phone system was installed. Since then, no alternative arrangements for private phone access had been made for residents without personal phones. Staff interviews confirmed that the only phone available for resident use was in the nurses' office and that staff presence was standard unless privacy was specifically requested. Even then, privacy was limited due to the need to keep the door ajar for supervision. There were also informal restrictions on when residents could use the phone, depending on staff availability, and some staff imposed time limits on calls. The facility's administration and nursing leadership acknowledged these practices and the absence of a portable phone, but no clarification or alternative had been provided to ensure residents' right to private communication.
Improper Disposal of Medical Records Breaches Resident Confidentiality
Penalty
Summary
The facility failed to maintain personal privacy and confidentiality of residents' personal and medical records by disposing of protected health information (PHI) in a public dumpster. This incident involved 136 residents, with medical records dating from 2008 to 2018 being placed in closed boxes and discarded off-site at a laundry building. The boxes were labeled with residents' names and years, making the information easily identifiable. The maintenance director was responsible for placing the records in the dumpster, and the administrator was notified of the breach after the records were discovered. Interviews revealed that the maintenance director was not aware of HIPAA regulations at the time of the incident and mistakenly disposed of the records in the dumpster. Other staff members, including an LPN and a housekeeper, demonstrated awareness of HIPAA requirements and stated that protected information should be placed in designated shred boxes or given to a charge nurse for proper disposal. The facility's policies required that PHI be managed and protected to prevent unauthorized release or disclosure, but these procedures were not followed in this instance, resulting in a breach of confidentiality.
Infection Control and EBP Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, specifically for Legionella and other water-borne pathogens. The facility's Legionella Water Management Plan was incomplete and outdated, with numerous sections left blank, including risk assessments, control measures, and documentation of maintenance activities. The facility lacked a Director of Maintenance to implement the program, and the Administrator acknowledged the absence of a responsible person for the Legionella program. The facility also failed to ensure that all residents received a two-step tuberculosis (TB) skin test upon admission. Several residents' medical records lacked documentation of the TB skin test, and there was no guidance in the facility's policy for completing the test. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed inconsistencies in the administration and documentation of the TB skin tests. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds or indwelling medical devices. Observations and interviews indicated that staff were not aware of which residents required EBP, and there were no signs or isolation carts to indicate the need for EBP. Staff interviews revealed a lack of understanding and training on EBP, and the Infection Preventionist was not present to ensure compliance.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and well-being of residents, as evidenced by the lack of activities for three sampled residents. Resident #19, who was cognitively intact, expressed a desire to go outside and engage in activities like playing cards and working with models. However, the resident's participation logs showed limited engagement, primarily in coffee club and bingo, with no activities scheduled on weekends. The resident reported a lack of activities on weekends and mentioned that the Activity Director was unsure of what to plan for the residents. Resident #23, who was moderately cognitively impaired, also experienced a lack of activities, particularly on weekends. The resident's participation logs indicated sporadic involvement in coffee club and bingo, with no logs available for September. The resident expressed dissatisfaction with the lack of activities and noted that due to behavior issues among some residents, they were no longer allowed to participate in activities with others. Similarly, Resident #36, who was cognitively intact and valued listening to music and going outside, reported a lack of activities and an absence of a current activities calendar. Observations from 9/9/24 to 9/11/24 confirmed the absence of activities on the unit. Interviews with staff, including CNAs and a CMT, revealed that activities were not conducted regularly, especially on weekends, and that the Activities Director was out due to illness. The Director of Nursing was unaware of the lack of activities on weekends and who was responsible for conducting them in the absence of the Activities Director. The deficiency in providing a comprehensive activities program had the potential to affect all residents in the facility.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was moderately cognitively impaired, had a care plan that included approaches for managing mental distress related to PTSD. However, observations and interviews revealed that staff were not fully aware of the resident's needs or specific triggers associated with PTSD. The resident exhibited behaviors such as pacing and restlessness, and sometimes expressed feelings of claustrophobia while smoking outside. Interviews with staff, including CNAs and LPNs, indicated a lack of awareness and training regarding the resident's PTSD diagnosis and associated care needs. Some staff were unsure of the resident's specific triggers and had not received recent training on PTSD. The MDS coordinator and the Director of Nursing also expressed a lack of knowledge about the resident's PTSD history and the frequency of trauma-informed care training provided to staff. The facility's Trauma Informed Care Policy outlined the need for staff training and the inclusion of trauma-informed care in the Quality Assurance Improvement Plan. However, the administrator and the Regional Nurse Consultant were unable to provide documentation of recent training sessions, indicating a gap in the implementation of the policy. This lack of training and awareness among staff contributed to the deficiency in providing appropriate trauma-informed care for the resident.
Narcotic Documentation and Count Discrepancies
Penalty
Summary
The facility failed to ensure accurate documentation of narcotic pain medication on the Medication Administration Record (MAR) and the narcotic count log for four residents. This deficiency was identified through interviews and record reviews, revealing discrepancies in the documentation and administration of narcotic medications. For instance, Resident #8's records showed that 102 Oxycodone tablets were documented as administered, but only 51 tablets were accounted for in the narcotic log, indicating a significant discrepancy. Additionally, there were instances where two tablets were signed out simultaneously, contrary to the physician's order for one tablet. Further investigation into Resident #23's records showed that 12 Hydrocodone tablets were unaccounted for, as the narcotic log and MAR did not match. Similarly, Resident #19's records indicated that 53 Norco tablets were documented as administered, but only 47 were signed out, leaving six tablets unaccounted for. Resident #36's records also showed discrepancies, with several Oxycodone tablets unaccounted for across different months. These inconsistencies highlight a failure in the facility's medication management and documentation processes. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that narcotic counts were not consistently conducted at shift changes, and there were numerous instances of missing signatures on narcotic count sheets. Staff admitted to not always counting liquid narcotics stored in the refrigerator, assuming they were full and unopened. The DON acknowledged responsibility for ensuring accurate narcotic counts and documentation but noted that there were many blanks on the narcotic sheets, indicating lapses in the facility's procedures.
Failure to Document and Educate on Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and education regarding pneumonia vaccinations for five residents upon their admission. The facility's policy, dated March 2022, mandates that all residents be offered pneumococcal vaccines and be assessed for eligibility prior to or upon admission. Additionally, residents or their representatives should receive education about the benefits, risks, and potential side effects of the vaccine. However, for Residents #15, #32, #36, #37, and #342, there was no documentation of their pneumonia vaccination status, no record of them being offered the vaccine, and no evidence that they were provided with the necessary educational information upon admission. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring that pneumonia education is provided upon admission. The Assistant Director of Nursing (ADON) was unsure who was responsible for this task, while the Director of Nursing (DON) acknowledged that pneumonia education and vaccination records should be documented in the resident's medical record upon admission. The DON also expressed uncertainty about whether the residents received the required education regarding pneumonia vaccines. This lack of documentation and clarity in roles contributed to the deficiency identified by the surveyors.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure the provision and documentation of education regarding the COVID-19 vaccine for both residents and staff. Specifically, five residents and five staff members were not provided with education about the benefits, risks, and potential side effects of the COVID-19 vaccine upon admission or hire. The facility's policy requires that each resident be offered the vaccine unless contraindicated and that education be provided in an understandable format. However, there was no documentation in the medical records of the sampled residents or the employment records of the sampled staff indicating that this education was provided. Interviews with facility staff revealed a lack of clarity and responsibility regarding the provision of COVID-19 vaccine education. The Assistant Director of Nursing (ADON) stated that they did not provide the education and assumed the Director of Nursing (DON) was responsible. The Regional Nurse expressed the belief that the facility was not required to obtain vaccination status or provide education since the Public Health Emergency had ended. The DON acknowledged that vaccination records should be maintained but was unsure if education was provided to residents and staff. The deficiency highlights a breakdown in the facility's processes for ensuring compliance with its own policies on COVID-19 vaccination education and documentation. The lack of documentation and education for both residents and staff indicates a systemic issue in the facility's approach to managing COVID-19 vaccination protocols. This failure to adhere to established policies could potentially impact the health and safety of both residents and staff.
Failure to Notify Resident and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of a hospital transfer/discharge for one resident, as well as to the Ombudsman, when the resident was transferred to the hospital. The incident involved a resident who was found on the floor and complained of pain in the right hip. The facility's physician was notified, and orders were given to send the resident to the emergency room. However, there was no documentation in the resident's paper chart or electronic health record indicating that a transfer/discharge notification was provided to the resident or the Ombudsman. Interviews conducted during the investigation revealed that the resident was unaware of receiving any written notification regarding the hospital transfer. A Licensed Practical Nurse (LPN) mentioned that the physician and family were typically notified in writing when residents were transported out of the facility, and that the Ombudsman must also be notified. The Director of Nursing (DON) confirmed that transfer/discharge notifications should have been issued to the resident and the Ombudsman, and that family and residents should be notified in writing with the reason for the transfer.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its Bed Hold policy to a resident who was transferred to the hospital. This deficiency was identified for one resident out of a sample of 13, in a facility with a census of 40 residents. The resident, who had moderate cognitive impairment, was sent to the emergency room following a fall and subsequent complaint of hip pain. A review of the resident's nurse progress notes and health records showed no evidence that the bed hold policy was issued. During interviews, the resident expressed unawareness of receiving any written notification regarding bed hold, and the LPN confirmed that bed hold policies must be provided in writing. The DON acknowledged that a bed hold policy should have been issued when residents are sent to the hospital.
Failure to Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) for a resident, as required by federal guidelines. The resident's admission MDS was completed, but the subsequent annual MDS, which was due within 366 days, was not completed. This oversight was identified during a review of the resident's assessments, which showed that the annual MDS was due but not completed. The facility's policy indicated that the assessment coordinator or designee was responsible for ensuring timely submission of assessments according to federal and state guidelines. The MDS Coordinator, who assumed the role after the annual MDS was due, stated that the previous program used for MDS completion did not provide notifications for past due assessments. The facility switched to a new program, which provided a list of residents and their MDS due dates, but this transition occurred after the annual MDS was already overdue. The Director of Nursing confirmed that MDS assessments should be completed timely, following the guidelines in the Resident Assessment Instrument Manual.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for a resident at the required intervals, as mandated by federal guidelines. The resident's admission MDS was completed on January 27, 2023, followed by the first and second quarterly MDS on April 24, 2023, and July 22, 2023, respectively. However, the third quarterly MDS, due on October 22, 2023, was not completed until November 2, 2023, making it one month late. Furthermore, the annual MDS due on January 28, 2024, was not completed, and no assessments were conducted after April 19, 2024. The MDS Coordinator, who assumed the role in February 2024, indicated that the previous software used for MDS completion did not provide notifications for overdue assessments, which contributed to the oversight. The facility transitioned to a new program on August 19, 2024, which provided a list of due assessments, but by then, the resident's MDS was already overdue. The Director of Nursing acknowledged that the MDS should be completed timely, in accordance with the Resident Assessment Instrument (RAI) manual.
Failure to Accurately Assess Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess a resident's oral and dental status, specifically regarding broken natural teeth and mouth pain. The resident, who had been admitted with diagnoses including dysphagia and gastrostomy status, was noted in the Admission Nursing Evaluation to have broken teeth. However, the Minimum Data Set (MDS) completed for the resident did not document any dental concerns, such as broken or missing teeth, or mouth or facial pain. This discrepancy indicates a failure in the assessment process, as the MDS did not reflect the resident's actual condition as observed and reported. Interviews with the MDS nurse and the Director of Nursing (DON) revealed that neither was aware of the resident's broken teeth, despite the resident expressing daily concerns about dental pain. The MDS nurse expected the MDS to accurately reflect the resident's condition based on nursing assessments, yet failed to capture the necessary documentation from the clinical chart. The DON also expected the MDS to be accurate and for the MDS nurse to conduct thorough assessments, highlighting a gap in communication and assessment practices within the facility.
Deficiencies in Communication and Dental Care Plans
Penalty
Summary
The facility failed to personalize a communication care plan for two residents, leading to deficiencies in their care. For the first resident, the admission Minimum Data Set (MDS) indicated that Spanish was their preferred language, and they were moderately cognitively impaired. Despite this, the communication care plan lacked specific interventions and details on how to assist the resident with communication. Observations showed the resident communicated in Spanish and used a translator application, while staff interviews revealed reliance on family members for translation and the use of hand gestures and basic Spanish by some staff. The MDS Coordinator acknowledged the care plan should have included specific communication interventions. The second resident had a history of dysphagia and gastrostomy status, with broken teeth noted in the Admission Nursing Evaluation. However, the MDS did not document any dental concerns, and the care plan lacked a dental care plan. Observations confirmed the resident had multiple missing and broken teeth, and the resident reported daily pain and concerns about their teeth. Interviews with staff, including the LPN, Social Services Designee, CNAs, and the MDS nurse, revealed a lack of awareness of the resident's dental issues. The Director of Nursing also confirmed the expectation that the care plan should reflect dental concerns. These deficiencies highlight the facility's failure to ensure comprehensive and personalized care plans for residents, particularly in addressing communication needs and dental health. The lack of specific interventions and awareness among staff contributed to the inadequate care planning for these residents.
Unqualified Activities Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by their own job description and state regulations. The facility's policy for the Activities Director (AD) was requested but not provided. The job description for the AD position specified that the individual must possess at least two years of college, be a qualified therapeutic recreation specialist, or have relevant experience or training. However, the current AD, who has been in the position for three months, did not meet these qualifications. The AD was a Certified Medication Technician (CMT) and a Certified Nurse Assistant (CNA) with a General Education Development (GED) and one year of college, but lacked the necessary experience or state-approved training. During an interview, the Administrator acknowledged that the AD did not have the required qualifications and needed to become qualified. An attempt to interview the AD was made, but the call was not returned. The facility census at the time was 40 residents, indicating that the deficiency could potentially impact a significant number of individuals. The lack of a qualified professional to direct the activities program represents a failure to comply with regulatory standards and the facility's own policies.
Failure to Provide Dental Care for Resident with Broken Teeth
Penalty
Summary
The facility failed to provide routine and emergency dental services to a resident, identified as Resident #37, who had multiple missing and broken teeth. The resident, who was admitted with a diagnosis of dysphagia, expressed daily pain and concern regarding their dental condition. Despite having an order for a dental consult and treatment, the resident was not seen by the dentist during the last visit on 7/25/24, and there was no documentation of a dental consent form being provided upon admission. Interviews with facility staff, including the Social Service Director (SSD), Licensed Practical Nurse (LPN), Certified Nurses Aides (CNAs), and the Director of Nursing (DON), revealed a lack of awareness regarding the resident's dental issues. The SSD was responsible for obtaining dental consents and scheduling appointments but was unaware of the resident's broken teeth and the last provision of dental services. The CNAs and MDS nurse also did not recognize the resident's dental needs, and the resident had not reported the need for dental care to them.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted correctly at the beginning of each shift, as required by federal regulations. The posted staffing sheets from 9/5/24 through 9/11/24 did not include the total actual hours worked for each discipline, such as RNs, LPNs, CMTs, CNAs, and NAs. Observations on multiple dates confirmed that the staffing sheets near the front nurse's station lacked this information, and no staffing sheets were posted in the locked Behavioral Unit. Interviews with staff, including a CNA, an LPN, and the Director of Nursing, revealed that the daily staffing sheet was only posted near the main nursing station and not in the Behavioral Unit. The Director of Nursing acknowledged that the form used by the facility did not show a total for the actual hours worked per discipline and confirmed that the staffing sheet should also be posted in the locked Behavioral Unit.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents. On the morning of April 3, 2024, in the dining room, one resident hit another on the head, causing an abrasion. The aggressor was wearing a ring, which contributed to the injury. The incident was triggered when the victim flipped the hat of another resident, which agitated the aggressor. The victim of the altercation had a history of severely impaired cognition due to Alzheimer's Disease and other medical conditions, while the aggressor was cognitively intact but had a history of verbal symptoms towards others. The aggressor admitted to hitting the victim and acknowledged that it was inappropriate behavior. There were no staff witnesses to the incident, and it was reported by a CNA who noticed the abrasion during a shower. Interviews with other residents and staff revealed that the victim had a history of behaviors that could provoke others, such as teasing and stealing. The aggressor was known to be easily annoyed and had a tendency to meddle. Despite these known behaviors, the facility did not prevent the altercation, resulting in a failure to protect the resident from abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Carroll House | 10.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Carrollton | 11.4 mi | ★★★★★ | 3 | 0 |
| Meyer Care Center | 15 mi | ★★★★★ | 1 | 0 |
| Lutheran Nursing Home | 15.7 mi | ★★★★★ | 4 | 0 |
| Living Center, The | 18.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.