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 Apple Rehab Clipper during CMS and state inspections, most recent first.
A resident with chronic kidney disease was readmitted after hospitalization, but the facility failed to reconcile differing Aranesp orders between the hospital discharge summary and the facility's records. Neither the provider nor nursing staff ensured the correct order was implemented, and no order was in place for weekly hemoglobin monitoring as required for safe administration of Aranesp. The discrepancy was identified by pharmacy, but not promptly addressed by the care team.
Two residents experienced significant medication errors when prescribed medications, including Aranesp, Heparin, and Trazodone, were not administered as ordered. Medication administration records lacked evidence of these medications being given on multiple occasions, and there was no documentation that providers were notified of the missed doses. The DON confirmed that physician orders were not followed and could not provide evidence that the residents were kept free from significant medication errors.
A resident with a percutaneous nephrostomy tube did not consistently receive care as ordered by the physician, including missed documentation of drain output, incomplete flushing of the tube, and missed site care. These deficiencies were identified through record review and staff interview after a complaint regarding staffing and medication errors.
The facility used an outdated diet manual and failed to utilize standardized recipes with nutritional information, resulting in menus that did not meet current national guidelines for resident nutrition. Staff interviews confirmed reliance on old standards and the absence of standardized recipes, with no evidence provided that menus met residents' nutritional needs.
Surveyors found that food items in the kitchen were not properly dated or stored, equipment was not kept clean, and staff handled ready-to-eat foods without gloves. Additionally, hot meals were routinely transported uncovered through hallways to resident rooms, contrary to food safety standards. These practices were acknowledged by dietary staff and the Food Service Director as routine.
A resident with a stage 4 pressure ulcer did not receive wound care according to physician orders and infection control protocols. During a dressing change, an RN failed to remove soiled gloves or perform hand hygiene before applying a new dressing, and used a collagen sheet not ordered by the physician. The DON confirmed that proper procedures and orders were not followed.
The facility failed to maintain acceptable nutritional status for two residents who experienced significant weight loss, and did not follow its own weight monitoring policy for three residents. Interventions were not implemented after severe weight loss, required weights were missed, and physicians were not notified as per policy. Staff interviews confirmed these deficiencies in monitoring and response.
Surveyors found that two medication carts contained multiple opened inhalers and a nasal spray that were either expired or not dated as required by facility policy and manufacturer instructions. RNs acknowledged the deficiencies, and the DON could not provide evidence that expired or undated medications were removed or properly labeled.
The facility did not obtain written authorization to hold personal funds for two residents. In both cases, documentation indicated that funds should be given directly to the residents, yet the facility maintained personal funds accounts for them without the required authorization forms. The Business Office Manager could not provide evidence of proper authorization during the survey.
The facility failed to maintain nutritional status for several residents by not adhering to its weight monitoring policy. Residents experienced significant weight changes without reweighs or new interventions, despite having conditions like dementia and COPD. The DNS and staff could not provide explanations or evidence of compliance, indicating systemic issues.
The facility did not complete annual performance reviews for three nurse aides, as required. A review of personnel files showed no evidence of evaluations for Staff F, G, and H, despite their long tenure. The DON could not provide documentation of these evaluations during an interview.
A facility failed to provide appropriate care for a resident with an indwelling catheter. The resident's care plan lacked an intervention for measuring urinary output every shift, and records showed inconsistent documentation of urinary output. Interviews with staff confirmed the deficiency in monitoring, indicating a failure to ensure adequate care for the resident's catheter needs.
A resident with Alzheimer's and hypertension had a care plan for lower leg edema that included ACE wraps, but surveyors found the plan was not implemented. The resident wore non-skid socks instead, and staff were unaware of the care plan. The DON acknowledged the oversight.
A resident with Parkinson's disease and dementia did not receive weekly body audits as ordered by a physician. The audits were not documented for four out of five opportunities. A registered nurse acknowledged the oversight, and the DON could not provide evidence of completed audits.
The facility failed to address irregularities identified by the Clinical Consultant Pharmacist for two residents on antipsychotic medications. Recommendations for monitoring and documentation were not reviewed or acted upon by the provider, and there was no evidence of ongoing monitoring for specified conditions or behaviors. Interviews with staff revealed uncertainty and lack of evidence regarding the review and implementation of the pharmacist's recommendations.
A surveyor found that a facility failed to store medications properly, with an undated open vial of tuberculin and expired lorazepam bottles in the medication room. A nurse acknowledged the oversight but could not explain why expired medications were not discarded, indicating a lapse in following storage and expiration policies.
The facility failed to ensure proper infection control practices, as a nurse used a blood glucose meter on a resident without following the disinfection policy, using only an alcohol wipe instead of EPA-approved disinfectants. Additionally, the facility did not implement Enhanced Barrier Precautions for residents with indwelling medical devices, lacking necessary signage and protective equipment use by staff.
The facility did not conduct mandatory QAPI training for its staff, including RNs and NAs hired between 2000 and 2022. A review showed no evidence of completed training, and the DON could not provide proof of training during an interview.
Failure to Reconcile Medication Orders and Monitor Lab Values After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident's medical care was properly supervised by a physician, specifically regarding the reconciliation of medication orders for Aranesp, a drug used to treat anemia in chronic kidney disease. Upon the resident's readmission following a hospitalization, there was a discrepancy between the hospital discharge order for Aranesp (25 mcg every 7 days) and the existing facility order (40 mcg every 28 days). The facility's records did not show evidence that nursing staff or providers reconciled these differing orders upon the resident's return. Both the physician and nurse practitioner documented that medications were reviewed and reconciled, but neither addressed the specific change in the Aranesp order from the hospital discharge summary. A pharmacy consultation also identified the discrepancy and requested clarification, but the issue was not promptly resolved. Additionally, there was no physician order in place to obtain weekly hemoglobin values to determine whether Aranesp should be administered or held, as required by the medication parameters. Interviews with the nurse practitioner and physician revealed that they were unaware the hospital discharge order had not been transcribed and that no order for routine hemoglobin monitoring was in place. The Director of Nursing Services confirmed that it was her expectation that both the medication order and the monitoring order should have been reconciled and implemented upon the resident's readmission.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the care of two residents. For one resident with chronic kidney disease, a physician's order for Aranesp 25 mcg every 7 days was not entered into the resident's record upon admission, and subsequent medication administration records showed that the medication was not given on multiple ordered dates. Laboratory results indicated that the resident's hemoglobin levels were within the range that required administration of Aranesp, yet there was no evidence that the medication was provided as ordered. Additionally, there was no documentation that the provider was notified of these missed doses, and the physician confirmed he was not informed of the missed administrations. Another resident admitted with dementia and vertebral fractures had physician's orders for Heparin and Trazodone, but the medication administration record did not show evidence that these medications were given on the day of admission. Again, there was no documentation that the provider was notified of the missed medication administrations. The Director of Nursing Services confirmed that it was her expectation that physician's orders should have been followed and was unable to provide evidence that the residents were kept free from significant medication errors.
Failure to Follow Physician Orders for Nephrostomy Tube Care
Penalty
Summary
A deficiency was identified when a resident with a percutaneous nephrostomy tube (PCN) did not receive care in accordance with physician's orders and professional standards of practice. Record review showed that the resident, admitted with an artificial opening of the urinary tract, had specific physician's orders for nephrostomy drain management, including emptying and recording output every shift, flushing the PCN with normal saline every day and evening shift, and performing PCN site care every two days. Documentation failed to show that these orders were consistently followed, with multiple instances where drain output was not recorded, the PCN was not flushed, and site care was not completed as ordered on specified dates and shifts. During an interview, the Director of Nursing Services confirmed that it was her expectation for the resident's PCN orders to be completed as prescribed. The findings were based on both record review and staff interview, and were initiated following a community complaint regarding concerns with facility staffing and medication errors.
Outdated Diet Manual and Lack of Standardized Recipes Result in Menu Deficiency
Penalty
Summary
The facility failed to provide dietary menus that meet the nutritional needs of residents in accordance with current national guidelines. Record review showed that the diet manual used by the facility was outdated, referencing the Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents 2014 Revision, while the most recent national guidelines were revised in 2020. Registered Dietitians confirmed that menus are generated corporately and reviewed using the outdated manual. The Director of Nutrition Services was unaware that the manual was not current and confirmed that the facility did not use standardized recipes. Further review of menus served over a one-week period revealed no evidence of standardized recipes on file. The recipe binder available contained recipes from internet sources without caloric or nutrient information. The Food Service Director confirmed that standardized recipes were not used in meal preparation. As a result, the facility could not provide evidence that their menus met the nutritional needs of residents as required by established national guidelines.
Deficiencies in Food Storage, Handling, and Meal Distribution
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and distribution practices. In the main kitchen, opened bottles of nectar thickened juices were found either undated or dated beyond the manufacturer's recommended use period, contrary to professional standards and FDA Food Code requirements. Additionally, the microwave in the kitchen contained visible food debris, indicating a lack of proper cleaning. During meal preparation, a cook was observed assembling a sandwich with bare hands, without using gloves, which is not in accordance with food safety protocols for handling ready-to-eat foods. Further observations during meal service revealed that hot food plates were transported uncovered from the steam table to resident rooms across significant distances in both the Portside and Starboard Units. Dietary aides acknowledged that plates were only covered if residents were not eating immediately, and the Food Service Director confirmed that carrying uncovered meals was standard practice. These actions failed to protect food from potential contamination as required by professional standards.
Failure to Follow Wound Care Protocol and Infection Control During Pressure Ulcer Treatment
Penalty
Summary
A resident with a stage 4 pressure ulcer to the sacral region was readmitted to the facility with physician orders for specific wound care, including cleaning with vashe wash, packing with alginate AG, and applying a collagen sheet daily and as needed. During a dressing change observed by a surveyor, a registered nurse failed to follow infection control procedures by not removing soiled gloves or performing hand hygiene after removing the soiled dressing, and then used the same gloves to apply the clean dressing. Additionally, the nurse applied a collagen sheet containing silver, which was not the type ordered by the physician. Staff interviews confirmed that the nurse did not change gloves or perform hand hygiene as required by facility policy and professional standards of practice. The Director of Nursing Services also acknowledged that the physician's order for the wound dressing was not followed and that proper infection control procedures were not observed during the dressing change.
Failure to Maintain Nutritional Status and Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for two residents who experienced actual weight loss. Specifically, one resident with dementia was re-admitted and experienced a severe weight loss of 8.5% in less than one month, followed by continued weight loss in subsequent months. The Registered Dietitian assessed the resident but did not implement any interventions, citing a belief that the initial weight was an error, and there was no evidence that the resident was reweighed to verify this. Additionally, there was no documentation that the physician was notified of the severe weight loss, as required by facility policy, and further weight loss occurred without intervention. Another resident with type 2 diabetes and a history of weight loss experienced a 7.74% severe weight loss in less than one month. The care plan required weekly weights, but the facility failed to obtain weights as ordered and did not implement interventions or notify the physician after the significant weight loss. The facility's records did not show that weights were obtained upon admission or at the required weekly intervals, as per policy and physician orders. A third resident with a neurodegenerative disorder and dysphagia experienced a 5.5% weight loss, but the facility did not reweigh the resident after a 5 lbs. discrepancy as required by policy, and missed additional weekly weights as ordered. Interviews with staff, including the Director of Nursing Services and the Medical Director, confirmed that interventions were not implemented and that required weight monitoring and physician notifications were not completed. The facility failed to follow its own weight monitoring policy for three residents reviewed.
Failure to Properly Store and Label Medications on Medication Carts
Penalty
Summary
Surveyor observations and staff interviews revealed that the facility failed to store and label drugs and biologicals in accordance with professional standards and facility policy for two medication carts. On the Portside Unit medication cart, a Breo Ellipta inhaler was found opened and labeled with a date indicating it was expired, and the RN present acknowledged the inhaler was expired. The manufacturer's instructions specify that the inhaler should be discarded six weeks after opening, which was not followed. On the Starboard Unit medication cart, several inhalers and a nasal spray were found opened and not dated, including a Trelegy Ellipta inhaler, a Breyna inhaler, a Flovent inhaler, a Fluticasone propionate nasal spray, and two Albuterol inhalers. Facility policy and manufacturer instructions require these medications to be dated when opened and discarded after a specified period or number of uses. The RN present confirmed that these medications were opened and not dated. The Director of Nursing Services was unable to provide evidence that the expired inhaler was removed or that the other medications were properly dated when opened.
Failure to Obtain Written Authorization for Holding Resident Personal Funds
Penalty
Summary
The facility failed to obtain written authorization to hold personal funds for two residents. For one resident, records showed a personal funds account balance, but the only available authorization form directed that personal needs funds be given directly to the resident, with no evidence of a form authorizing the facility to hold the funds. Similarly, for another resident, the personal funds account had a balance, but the signed authorization form also directed that funds be given directly to the resident, and no documentation was found authorizing the facility to retain the funds. During an interview, the Business Office Manager was unable to provide evidence that the required authorization forms were in place for these residents.
Failure in Weight Monitoring and Nutritional Status Maintenance
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for seven out of eight residents reviewed, as evidenced by inadequate weight monitoring and failure to implement necessary interventions. The facility's policy required residents to be weighed weekly for four weeks upon admission and then monthly, with reweighs mandated for any weight discrepancy of 5 pounds or more. However, the records revealed multiple instances where residents experienced significant weight changes without reweighs being conducted, contrary to the facility's policy. For instance, one resident with a gastrostomy tube experienced a weight loss of 22.4 pounds within a short period, yet there was no evidence of a reweigh or new interventions to address the weight loss. Another resident, admitted on hospice services, did not have monthly weights recorded, and there was no physician's order to discontinue weight monitoring. Additionally, a resident with Alzheimer's Disease and paraplegia experienced a weight loss of 5.6 pounds without a reweigh, and no monthly weight was recorded for May 2024. The facility's failure to adhere to its weight monitoring policy was further highlighted by the lack of reweighs for residents who experienced weight fluctuations of 5 pounds or more. This included residents with conditions such as vascular dementia, hypertension, and chronic obstructive pulmonary disease. The Director of Nursing Services (DNS) and other staff members were unable to provide explanations or evidence of compliance with the policy, indicating a systemic issue in the facility's weight monitoring practices.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete an annual performance review for every nurse aide at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that the personnel files for three nursing assistants, Staff F, G, and H, lacked evidence of a completed performance evaluation within the last year. Staff F was hired on November 23, 2022, Staff G on July 17, 2007, and Staff H on December 4, 2000. During an interview with the Director of Nursing Services on May 22, 2024, she was unable to provide documentation of the required evaluations for these employees.
Inadequate Monitoring of Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling catheter. The resident, who was admitted with chronic obstructive pulmonary disease and atrial fibrillation, required a supra-pubic tube due to urinary retention. The care plan for the resident did not include an intervention for measuring and recording urinary output every shift, which is essential for assessing renal function and urinary drainage. A review of the resident's records from May 9, 2024, to May 21, 2024, showed that urinary output was documented only 9 times out of 39 opportunities. The recorded outputs varied, with several instances showing 0 ml, indicating a lack of consistent monitoring. Interviews with the Staff Development Coordinator and the Director of Nursing Services confirmed the absence of documentation for urinary output every shift, highlighting the facility's failure to ensure adequate monitoring and care for the resident's urinary catheter needs.
Failure to Implement Care Plan for Resident with Edema
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with lower leg edema. The resident, who was admitted in April 2024 with Alzheimer's disease and hypertension, had a care plan initiated on April 8, 2024, which included the application of ACE wraps to both lower legs in the morning and their removal at bedtime. However, surveyor observations on May 20 and May 22, 2024, revealed that the resident was not wearing the ACE wraps as prescribed but was instead observed wearing non-skid socks. Interviews with the resident and staff members indicated a lack of awareness and implementation of the care plan. The resident stated that they had been wearing non-skid socks since admission and would wear the ACE wraps if provided. The primary nursing assistant and a registered nurse were both unaware of the care plan for the resident's bilateral leg edema. The Director of Nursing Services acknowledged that the care plan had not been implemented, confirming the deficiency in providing the necessary medical and nursing care as identified in the comprehensive assessment.
Failure to Follow Physician's Orders for Weekly Body Audits
Penalty
Summary
The facility failed to ensure that a resident received treatment and services in accordance with professional standards of practice by not following a physician's order for weekly body audits. The resident, who was admitted in April 2024, had diagnoses including Parkinson's disease and dementia. A physician's order dated April 17, 2024, required a body audit on admission and weekly by a licensed nurse on shower day, with documentation on the Body Audit Form. However, record reviews revealed that the weekly body audits were not completed and documented for four out of five opportunities between April 17, 2024, and May 21, 2024. During interviews, a registered nurse acknowledged the failure to complete and document the weekly body audits as per the physician's order. The Director of Nursing Services was also unable to provide evidence that the audits were completed and documented as required.
Failure to Act on Pharmacist's Recommendations for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were addressed for two residents. For Resident ID #10, the pharmacist's Consultation Report recommended specific monitoring and documentation for the antipsychotic medication Seroquel, including monitoring for neuroleptic malignant syndrome, metabolic complications, and medication-specific side effects. However, the resident's medical record did not show evidence that these recommendations were reviewed or acted upon by the provider. Additionally, there was no documentation of ongoing monitoring for the specified conditions or behaviors. Similarly, for Resident ID #12, the pharmacist's Consultation Report included recommendations for monitoring and documentation related to the use of Haloperidol, another antipsychotic medication. The report suggested developing a care plan for mood or behavior, monitoring for neuroleptic malignant syndrome, metabolic complications, and medication-specific side effects. However, the resident's care plan lacked evidence of these actions, and the provider did not review or act upon the pharmacist's recommendations. Interviews with the Registered Nurse Practitioner and the Director of Nursing Services revealed uncertainty and lack of evidence regarding the review and implementation of the pharmacist's recommendations.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as observed by a surveyor in the medication storage room. During the inspection, it was found that a vial of tuberculin purified protein derivative was opened and undated, despite the manufacturer's instructions stating that the vial should be discarded after 30 days once opened. Additionally, there were issues with the storage of lorazepam intensol, a medication used to treat anxiety. Two unopened bottles of lorazepam intensol were found with expired manufacturer dates, and one opened bottle had a documented open date, but it was not discarded after the 90-day period as per the manufacturer's instructions. During an interview following the observation, Registered Nurse, Staff C, acknowledged the oversight regarding the undated tuberculin vial and the expired lorazepam bottles. Staff C was unable to provide an explanation for why the expired lorazepam bottles were not discarded. This indicates a lapse in following the facility's policy on the storage and expiration dating of medications and biologicals, which requires staff to record the date opened on medication containers and adhere to manufacturer guidelines for expiration dates.
Infection Control Deficiencies in Glucometer Disinfection and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to potential infection risks. Specifically, a registered nurse, identified as Staff C, was observed using a blood glucose meter on a resident without properly disinfecting it according to the facility's policy. The policy required the use of specific EPA-approved disinfectants, but Staff C used an alcohol wipe instead. This practice was confirmed during an interview with Staff C, who admitted to using the glucometer for multiple residents without following the correct disinfection procedure. The Director of Nursing Services acknowledged the non-compliance with the disinfection policy but could not provide evidence of proper disinfection. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, as required by their policy. During observations, several residents with devices such as a supra-pubic tube, gastrostomy tube, urinary catheter, and a peripherally inserted central catheter were not provided with the necessary EBP signage. Furthermore, staff members, including the Director of Nursing Services, were observed not wearing appropriate protective equipment, such as gowns and gloves, when interacting with these residents. The Director of Nursing Services was unable to explain the lack of adherence to the infection control policy for EBP during an interview.
Failure to Conduct Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to conduct mandatory training for all staff on the Quality Assurance and Performance Improvement (QAPI) program. A record review revealed that several staff members, including registered nurses and nursing assistants, did not complete the required QAPI training. Specifically, the records showed that an RN hired in 2022, another RN hired in 2020, and a third RN hired in 2017, along with nursing assistants hired in 2022, 2007, and 2000, had not received this training. Further review indicated that no current staff members had completed the mandatory QAPI training. During an interview, the Director of Nursing Services was unable to provide evidence that the facility had conducted the required training for all staff.
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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 Westerly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Of Westerly Nursing Center | 2.6 mi | ★★★★★ | 9 | 0 |
| Westerly Health Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Pendleton Rehabilitation And Nursing Center | 8.9 mi | ★★★★★ | 1 | 0 |
| Avalon Health Care Center At Stoneridge | 8.9 mi | ★★★★★ | 1 | 0 |
| Apple Rehab Mystic | 9.4 mi | ★★★★★ | 5 | 0 |
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