Inspection Reports for
Apple Ridge Care Center

The complaint investigation found that Resident #2 and Resident #3 engaged in a physical and verbal altercation on 12/26/25 when no staff were present on the behavioral locked unit. The altercation was related to delayed medication administration caused by a facility internet outage. Witnesses and staff interviews confirmed the incident and lack of supervision. The CNA assigned to the unit had called in sick, and the CMT left the unit unattended to print medication records.

The facility failed to prevent verbal and physical abuse between two residents on the behavioral locked unit due to inadequate staffing and supervision. The altercation occurred when Certified Medication Technician (CMT) A left the unit unattended to print medication records during an internet outage, resulting in Resident #2 striking Resident #3. The facility did not have staff present on the locked unit at the time, violating expected supervision standards.

The facility failed to ensure residents on the locked unit had reasonable access to private telephone conversations. Residents without personal phones had to use the nurses' office phone, where privacy was not ensured as staff remained present and conversations could be overheard. The facility lacked a portable or private phone option since a new phone system was installed about a year ago.

Complaint #1542769 alleging HIPAA noncompliance due to improper disposal of medical records was substantiated. The Maintenance Director admitted to disposing of records in a public dumpster without knowledge of HIPAA regulations and has since been educated.

The facility failed to maintain the privacy and confidentiality of residents' medical records by disposing of 136 residents' records in a public dumpster. The records were retrieved and properly destroyed by incineration. The Maintenance Director was responsible for the improper disposal and has since been educated on HIPAA compliance.

The facility was found deficient in multiple areas including failure to provide timely transfer/discharge notifications, incomplete and inaccurate Minimum Data Set (MDS) assessments, failure to personalize care plans, inadequate activities programming, unqualified activities director, failure to provide trauma informed care, incomplete nurse staffing postings, narcotic medication documentation errors, lack of routine and emergency dental care, incomplete tuberculosis testing, inadequate infection prevention and control program including Enhanced Barrier Precautions, and failure to provide and document resident and staff COVID-19 and pneumonia vaccination education and status.

The complaint investigation found a resident-to-resident altercation on 4/4/24 where Resident #2 hit Resident #1 on the top of the head with a ring on, causing an abrasion. Resident #2 admitted to the incident. There were no staff witnesses. Staff were educated post-incident and Resident #2 was placed on 15-minute checks and educated to avoid Resident #1. Multiple resident and staff interviews confirmed the incident and behaviors.

The facility failed to ensure Resident #1 was free from abuse when Resident #2 struck Resident #1 on the head causing injury. The incident was investigated, staff were educated on abuse and neglect, resident safety checks were implemented, and care plans updated. The deficiency was corrected by 4/8/24.

The complaint investigation found that staff verbally abused a resident after a fall, including inappropriate language and disrespectful comments. The complaint was substantiated, leading to suspension and termination of involved staff.

The facility failed to ensure staff treated one sampled resident respectfully while assisting the resident off the floor after a fall. Several staff members used inappropriate language and behavior towards the resident, resulting in suspensions and terminations. The facility provided education on proper communication to all staff.

The complaint investigation found substantiated incidents of abuse involving Resident #1 hitting Resident #2 with a broom causing a small cut, and Resident #1 hitting Resident #3 multiple times in the head. The facility was notified and took actions including safety checks and hospital evaluation for Resident #1. Staffing shortages were noted during incidents.

The facility failed to ensure three residents were free from abuse, with documented incidents of Resident #1 hitting Resident #2 with a broom causing a cut, and hitting Resident #3 multiple times in the head. The facility had interventions including 15-minute safety checks and psychiatric evaluations, but staffing levels were insufficient to provide one-to-one monitoring during some incidents.

The facility had multiple deficiencies including failure to separate resident funds from operating accounts, incomplete employee background checks, lack of PASARR Level I screening for a resident with new mental health diagnoses, incomplete CPR certification documentation and awareness, improper maintenance and storage of nebulizer equipment, unclean kitchen storage areas and equipment, and failure to follow proper infection control practices during perineal care.

The facility was found deficient in multiple areas including failure to submit timely Third Party Liability forms after resident death, incomplete investigation and reporting of alleged resident abuse, failure to check CNA registry for new hires, failure to complete required PASARR Level II screening for a resident with mental illness, and multiple food safety and sanitation violations in the dietary department.