Inspection Reports for
Apple Ridge Care Center
100 WEST THOMAS AVE, WAVERLY, MO, 64096-9143
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
167% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
72% occupied
Based on a December 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Dec 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a verbal and physical altercation between two residents (Resident #2 and Resident #3) on the behavioral locked unit when the unit was left unsupervised by staff.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to prevent verbal and physical abuse between residents due to lack of supervision on the behavioral locked unit.
Failed to ensure adequate staffing coverage to provide supervision and oversight for residents on the behavioral locked unit.
Report Facts
Residents affected: 2
Facility census: 43
Sampled residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Left the behavioral locked unit unattended to print medication records, leading to the altercation |
| LPN B | Licensed Practical Nurse | Responded to the incident and provided interview details about staffing and incident |
| Administrator | Provided statements regarding expectations for supervision and staffing on the behavioral locked unit | |
| Staffing Coordinator | Provided statements about staffing expectations for the behavioral locked unit | |
| CNA A | Certified Nurse Aide | Interviewed about staffing requirements and supervision on the behavioral locked unit |
| CNA B | Certified Nurse Aide | Interviewed about staffing requirements and supervision on the behavioral locked unit |
| CNA C | Certified Nurse Aide | Interviewed about instructions to never leave the behavioral unit unsupervised |
Inspection Report
Routine
Census: 44
Deficiencies: 1
Date: Dec 19, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding residents' access to and privacy in their use of communication methods, specifically telephone use on the locked unit.
Findings
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.
Deficiencies (1)
Failed to ensure residents on the locked unit had the opportunity to make and receive phone calls without being overheard.
Report Facts
Residents on locked unit: 16
Total facility census: 44
Sampled residents: 8
Residents on locked unit sampled: 5
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed staying in nurses' office during residents' phone calls and involved in privacy issues |
| CMT A | Certified Medication Technician | Reported staff always stay in nurses' office during residents' phone calls unless privacy requested |
| Director of Nursing | Director of Nursing | Stated residents should have unrestricted phone access and no time limits |
| Administrator | Administrator | Stated residents should have unrestricted phone access and privacy accommodations |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jul 18, 2025
Visit Reason
The inspection was conducted due to a complaint alleging improper disposal of residents' personal and medical records in a public dumpster, potentially violating HIPAA regulations.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide personal privacy and confidentiality of residents' personal and medical records by disposing of the records in a public dumpster.
Report Facts
Residents affected: 136
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Responsible for disposing of medical records in public dumpster and later educated on HIPAA compliance | |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding HIPAA knowledge and disposal procedures |
| Housekeeper A | Interviewed regarding HIPAA knowledge and handling of protected information | |
| Administrator | Notified of noncompliance and interviewed about the incident and corrective actions |
Inspection Report
Routine
Census: 40
Deficiencies: 14
Date: Sep 11, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, infection control, medication management, activities, and facility safety.
Findings
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.
Deficiencies (14)
Failed to provide written notification of hospital transfer/discharge to resident and Ombudsman.
Failed to provide written notification of facility's Bed Hold policy upon hospital transfer.
Failed to complete annual and quarterly Minimum Data Set (MDS) assessments timely and accurately.
Failed to personalize communication care plans for residents with cognitive impairment and language needs.
Failed to provide ongoing activities program meeting residents' interests and needs, especially on weekends.
Activities program was not directed by a qualified professional as required by state regulations.
Failed to provide trauma informed care for resident with PTSD including lack of staff awareness of triggers and care approaches.
Failed to post nurse staffing information correctly including total and actual hours worked per shift in all required locations.
Failed to ensure accurate documentation and auditing of narcotic medication administration and counts for multiple residents.
Failed to provide routine and 24-hour emergency dental care to resident with broken teeth and pain.
Failed to provide and document two-step tuberculosis skin testing for residents upon admission.
Failed to establish and maintain a comprehensive infection prevention and control program including Legionella water management and Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices.
Failed to ensure staff compliance with Enhanced Barrier Precautions for residents with wounds and feeding tubes, including lack of signage and isolation carts.
Failed to provide and document resident and staff education and vaccination status for pneumonia and COVID-19 vaccines upon admission and hire.
Report Facts
Residents affected: 40
Narcotic tablets unaccounted: 12
Narcotic tablets unaccounted: 6
Narcotic tablets unaccounted: 3
Narcotic tablets unaccounted: 11
Narcotic tablets unaccounted: 2
Oxycodone tablets unaccounted: 14
Narcotic count documentation missing: 161
Inspection Report
Life Safety
Census: 40
Capacity: 60
Deficiencies: 11
Date: Sep 11, 2024
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility failed to establish and maintain a comprehensive emergency preparedness program meeting all CMS requirements. Deficiencies were found in emergency water supply, communication plans, emergency preparedness training, fire safety including exit door locking and fire extinguisher maintenance, and fire drill documentation.
Deficiencies (11)
E001 The facility failed to establish and maintain a comprehensive Emergency Preparedness plan that meets CMS requirements including hazard vulnerability assessment and emergency water supply.
E015 The facility failed to ensure adequate subsistence needs for staff and patients during emergencies, including sufficient emergency water supply and temperature control.
E032 The facility failed to develop and maintain an emergency preparedness communication plan including primary and alternate means of communication with staff and emergency agencies.
E037 The facility failed to provide adequate emergency preparedness training to all staff and maintain documentation of such training.
K222 The facility failed to ensure that all clinical security exit doors were equipped with approved delayed egress locking arrangements that release upon loss of power or alarm activation.
K355 The facility failed to ensure that Class K fire extinguishers were properly installed, inspected, and maintained with current inspection records.
K711 The facility failed to maintain a comprehensive fire safety evacuation and relocation plan with adequate staff training and posted evacuation diagrams.
K712 The facility failed to maintain current and complete fire drill records including documentation of all required drills and staff participation.
K761 The facility failed to conduct required annual inspection, testing, and maintenance of fire doors and smoke barriers to ensure proper operation and labeling.
K914 The facility failed to maintain electrical systems and receptacles with required inspections and documentation, including patient room outlets.
K923 The facility failed to properly secure and label oxygen storage areas and maintain compliance with NFPA standards for gas equipment storage.
Report Facts
Facility census: 40
Licensed capacity: 60
Gallons of emergency water: 57
Missing fire drill records: 6
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
The document is a Plan of Correction related to a deficiency cited during a survey conducted on 2024-04-15 regarding abuse and neglect at Apple Ridge Care Center.
Findings
The facility failed to ensure one sampled resident was free from abuse when another resident hit them causing a small abrasion. The incident involved multiple residents and was investigated with interviews and record reviews confirming the abuse and neglect.
Deficiencies (1)
F 600: The facility failed to ensure freedom from abuse, neglect, and exploitation as Resident #1 was hit by Resident #2 causing a small abrasion to the head. The deficiency was corrected on 2024-04-08.
Report Facts
Resident census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John M. Boyer | Administrator | Signed the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #2 hit Resident #1 causing a small abrasion to the top of Resident #1's head on 4/4/24.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect Resident #1 from abuse when Resident #2 hit Resident #1 causing a small abrasion to the head.
Report Facts
Residents affected: 4
Census: 38
Date of incident: Apr 4, 2024
Date deficiency corrected: Apr 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Completed Resident Abuse/Neglect Investigation Report and notified of incident | |
| Director of Regional Consulting | Notified of noncompliance and confirmed staff education on abuse/neglect | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding incident, present but did not witness altercation | |
| Certified Nursing Assistant (CNA) A | Reported abrasion to nurse and intervened in resident behaviors | |
| Certified Nursing Assistant (CNA) B | Found abrasion on Resident #1 and reported to charge nurse |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 1
Date: Oct 25, 2023
Visit Reason
The visit was conducted to address a deficiency related to the exercise of resident rights, specifically regarding staff treatment of a sampled resident after a fall.
Findings
The facility failed to ensure staff treated one sampled resident in a respectful manner after a fall. Several staff members were suspended and later terminated due to verbal inappropriate behavior toward the resident.
Deficiencies (1)
F 550 Resident Rights: The facility failed to ensure staff treated one sampled resident respectfully while assisting the resident off the floor after a fall. Staff were verbally inappropriate and suspended or terminated following investigation.
Report Facts
Facility census: 43
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Oct 25, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding staff failing to treat a resident with dignity and respect after a fall incident.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Staff failed to treat a resident with dignity and respect after a fall, using inappropriate language and behavior.
Report Facts
Residents affected: 1
Census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Named in inappropriate communication and terminated after investigation. |
| LPN A | Licensed Practical Nurse | Named in inappropriate communication and terminated after investigation. |
| CNA A | Certified Nurse Assistant | Involved in the incident and suspended pending investigation. |
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 2
Date: Aug 7, 2023
Visit Reason
The inspection was conducted to investigate allegations of abuse and neglect involving three residents at Apple Ridge Care Center.
Complaint Details
The visit was complaint-related due to allegations of abuse involving three residents. The complaint was substantiated as the facility failed to prevent abuse incidents.
Findings
The facility failed to ensure three residents were free from abuse, including incidents where Resident #1 hit Residents #2 and #3. The facility's abuse prevention program and staff interventions were reviewed, and corrective actions were planned.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent verbal, mental, sexual, or physical abuse, as Resident #1 hit Residents #2 and #3 causing injuries. The facility census was 42 residents at the time.
A8023 Develop/Implement Abuse and Neglect Policies: The facility did not meet the requirement to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, resulting in a Class II deficiency.
Report Facts
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cameron S. Mueller | Director of Regional Consulting | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
The inspection was conducted due to complaints regarding abuse incidents involving three residents at the facility, specifically incidents where Resident #1 physically abused Residents #2 and #3.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident, resulting in injuries and repeated aggressive incidents.
Report Facts
Residents affected: 3
Facility census: 42
15 minute safety checks duration: 72
BIMS score: 5
BIMS score: 15
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Notified Administrator and physician of incidents, involved in investigation and resident monitoring |
| CNA A | Certified Nurse Assistant | Only staff on locked unit during initial incident, separated residents and notified LPN A |
| LPN B | Licensed Practical Nurse | Witnessed Resident #1 hitting Resident #3, separated residents, involved in resident monitoring and reporting |
| CNA B | Certified Nurse Assistant | On break during incident, later monitored residents and reported behaviors |
| Administrator | Notified of incidents, interviewed residents, made decisions on psychiatric evaluation and placement | |
| Physician | Notified of incidents, ordered evaluations and treatments |
Inspection Report
Life Safety
Census: 44
Capacity: 60
Deficiencies: 9
Date: Mar 2, 2023
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements and the 2012 edition of the Life Safety Code. Deficiencies included lack of an updated emergency preparedness plan, inadequate fire door self-closing mechanisms, fire alarm system out of service, incomplete fire watch policy, and insufficient fire extinguisher inspections.
Deficiencies (9)
E004 Emergency Preparedness Plan was not developed, maintained, or reviewed annually as required, lacking documentation of annual review and signatures.
K321 Hazardous areas lacked self-closing doors and proper ventilation, potentially affecting 25 residents and staff in two smoke zones.
K346 Fire alarm system was out of service for more than 4 hours without proper notification or fire watch procedures.
K355 Portable fire extinguishers were not inspected monthly as required; one extinguisher had not been checked since January 2023.
K363 Corridor doors lacked self-closing and latching mechanisms, risking containment of smoke and fire spread affecting 28 residents.
K521 HVAC system failed to provide adequate ventilation and negative air flow in residents' toilet rooms, affecting 29 residents.
K712 Fire drills were not conducted quarterly on each shift, and fire drill records were incomplete or missing verification.
K761 Door inspections and testing were not conducted annually, and records of inspections were incomplete or missing.
K923 Oxygen storage room lacked proper fire-resistant construction and storage safeguards, risking fire hazards.
Report Facts
Facility census: 44
Total licensed bed capacity: 60
Number of deficient smoke zones affected: 2
Number of residents affected by deficient smoke doors: 28
Number of residents affected by ventilation issues: 29
Fire drills frequency: 4
Inspection Report
Routine
Census: 44
Deficiencies: 9
Date: Mar 2, 2023
Visit Reason
Routine inspection of Apple Ridge Care Center to assess compliance with regulatory requirements including resident rights, financial management, employee background checks, PASARR screening, CPR certification, respiratory care, food safety, and infection control.
Findings
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.
Deficiencies (9)
Failed to ensure resident funds were placed in an account separate from the facility operating account and did not provide timely refund of personal funds for one resident.
Failed to maintain required escrow amount for resident trust funds affecting 35 residents.
Failed to ensure code status was accurately reflected on Physician's Orders and Care Plan for one resident.
Failed to complete required employee background checks, reference checks, and quarterly Employee Disqualification List checks for multiple employees.
Failed to ensure PASARR Level I screening was completed for a resident with new mental disorder diagnoses.
Failed to ensure all staff were aware of CPR policy, maintain current CPR certification documentation for all staff, and ensure CPR certified staff coverage on all shifts.
Failed to maintain and store nebulizer equipment using infection control practices for one resident.
Failed to maintain cleanable surfaces in kitchen storage areas, lacked trash cans with self-opening and closing lids near hand washing sinks, and had grease build-up on spice containers.
Failed to maintain an infection control program ensuring proper hand hygiene, glove use, and perineal care for one resident.
Report Facts
Facility census: 44
Residents affected: 35
Residents affected: 12
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees affected: 7
Employees with CPR certification: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Night shift nurse with CPR certification |
| LPN C | Licensed Practical Nurse | Night shift nurse with CPR certification |
| CNA B | Certified Nursing Assistant | Observed performing perineal care with improper hand hygiene |
| Administrator | Provided information on CPR certification and employee background check deficiencies | |
| Business Office Manager | Interviewed regarding resident funds and escrow deficiencies | |
| Dietary Supervisor | Interviewed regarding kitchen storage and cleaning deficiencies | |
| Maintenance Supervisor | Interviewed regarding kitchen storage solutions | |
| Certified Medication Technician A | Interviewed regarding nebulizer use and infection control | |
| Certified Medication Technician B | Interviewed regarding CPR certification awareness | |
| CNA A | Interviewed regarding CPR certification awareness | |
| Dietary Aide A | Interviewed regarding CPR certification awareness | |
| Registered Nurse A | Interviewed regarding CPR certification awareness | |
| LPN A | Interviewed regarding CPR certification awareness and infection control | |
| CNA C | Interviewed regarding infection control practices | |
| Social Services Designee | Interviewed regarding PASARR screening and code status |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 2
Date: Nov 3, 2022
Visit Reason
The inspection was conducted to investigate and document deficiencies related to resident safety, specifically regarding supervision and accident hazards, following an incident where a resident fell outside unsupervised.
Findings
The facility failed to provide adequate supervision to a resident identified as a fall risk, resulting in the resident falling approximately 25 feet down a hill and sustaining injuries. The facility's policies and interventions to prevent accidents and elopement risks were reviewed and found insufficient in practice.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide supervision for a resident identified as a fall risk who fell outside unsupervised, sustaining abrasions and a fracture. Multiple residents were identified as at risk for elopement and falls without adequate supervision.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: The facility did not have adequate procedures to ensure oversight and supervision of residents on voluntary leave, failing to meet regulatory requirements.
Report Facts
Resident census: 43
Inspection Report
Routine
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 6
Date: Dec 3, 2020
Visit Reason
The document is a plan of correction submitted by Apple Ridge Care Center in response to deficiencies cited during a survey conducted on 12/03/2020.
Findings
The facility was cited for multiple deficiencies including failure to submit Third Party Liability forms timely, failure to fully investigate an alleged incident of non-consensual sexual touching, failure to develop and implement abuse/neglect policies, failure to check the Certified Nursing Assistant Registry for employees, failure to report alleged violations timely, failure to ensure food safety and sanitation, and failure to complete PASARR screenings as required.
Deficiencies (6)
F-569 Notice and Conveyance of Personal Funds: The facility failed to submit a Third Party Liability form within 30 days after the death of a resident.
F-600 Freedom from Abuse and Neglect: The facility failed to fully investigate an alleged incident of non-consensual sexual touching for one sampled resident.
F-607 Develop/Implement Abuse/Neglect Policies: The facility failed to develop and implement written policies and procedures to prevent abuse, neglect, and exploitation of residents.
F-609 Reporting of Alleged Violations: The facility failed to report an alleged incident of non-consensual sexual touching to the State Agency within five working days.
F-644 Coordination of PASARR and Assessments: The facility failed to ensure one sampled resident with a mental disorder had an updated PASARR Level II screening as required.
F-812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain food containers properly and ensure food service areas were clean and sanitary.
Report Facts
Facility census: 40
Days late for TPL form submission: 113
Number of sampled residents: 12
Number of sampled employees: 5
Inspection Report
Life Safety
Census: 40
Capacity: 60
Deficiencies: 6
Date: Dec 3, 2020
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and fire safety codes.
Findings
The facility was found not in compliance with emergency preparedness communication plan requirements and failed to maintain certain fire safety standards including sealing wall penetrations and maintaining sprinkler heads free from corrosion. The facility census was 40 residents with a licensed capacity of 60 beds.
Deficiencies (6)
E031 Emergency Officials Contact Information: The facility failed to include the location of contact information for off duty personnel and the phone number for the local fire department in the Water Main Break Plan. This affected all residents and staff.
K161 Building Construction Type and Height: The facility failed to seal wall penetrations that could allow passage of smoke into interstitial spaces, potentially affecting at least 20 residents in two of four smoke zones.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain two sprinkler heads in the East Hall shower room free from corrosion, potentially affecting one smoke zone.
A2034 Sprinkler System-Test/Maintain: The facility did not meet inspection and maintenance requirements for sprinkler systems as per NFPA standards.
A3001 Substantially Constructed/Maintained: The building was not maintained in good repair according to construction standards applicable to licensed facilities.
A4013 Policies/Procedures-Operational: The facility lacked adequate policies and procedures to ensure resident health and safety, including emergency treatment and infection control.
Report Facts
Facility census: 40
Licensed capacity: 60
Smoke zones affected: 2
Sprinkler heads affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tristan Wilkinson | LNHA | Administrator signing plan of correction |
| Maintenance Director | Named in findings related to sprinkler head corrosion and wall penetrations | |
| Facility Administrator | Educated on emergency preparedness communication plan and corrective actions | |
| Director of Regional Consulting | Provided education to Facility Administrator on emergency preparedness communication plan |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 6
Date: Dec 3, 2020
Visit Reason
The inspection was conducted as an annual survey of Apple Ridge Care Center to assess compliance with federal and state regulations related to resident care, abuse prevention, pre-admission screening, and food safety.
Findings
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.
Deficiencies (6)
Failed to submit Third Party Liability form within 30 days after resident death.
Failed to fully investigate an alleged incident of non-consensual sexual touching for a resident.
Failed to check CNA Registry for two new hires to ensure no Federal Indicator for abuse/neglect.
Failed to timely report alleged abuse and investigation results to State Agency within 5 working days.
Failed to ensure updated PASARR Level II screening for resident with mental illness.
Failed to label food containers, maintain cleanliness and repair of kitchen equipment and environment, and ensure adequate lighting in food preparation areas.
Report Facts
Residents affected: 40
Days late for TPL form submission: 113
Number of sampled residents with abuse investigation deficiency: 1
Number of sampled employees without CNA registry check: 2
Number of sampled residents without updated PASARR Level II screening: 1
Number of fluorescent lights not illuminated: 4
Number of cereal containers uncovered during light fixture removal: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | New hire unaware of TPL form submission requirements and CNA registry checks | |
| Administrator | Responsible for abuse reporting and training oversight | |
| Licensed Practical Nurse A | LPN | Involved in abuse allegation reporting and investigation |
| Director of Nursing | DON | Responsible for abuse investigation and reporting |
| Dietary Manager | DM | Responsible for dietary sanitation and labeling |
| Licensed Practical Nurse A | LPN | Charge nurse during abuse allegation |
Inspection Report
Routine
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Life Safety
Census: 43
Capacity: 60
Deficiencies: 4
Date: Aug 2, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations at Apple Ridge Care Center.
Findings
The facility failed to meet several fire safety requirements including sealing wall penetrations that allow smoke passage, repairs to the range hood, maintaining smoke barriers, and ensuring proper fire drill records. These deficiencies potentially affected multiple residents and staff.
Deficiencies (4)
K161: The facility failed to seal wall penetrations that could allow smoke passage into interstitial spaces throughout the building, affecting multiple smoke zones and residents.
K324: The facility failed to make necessary repairs to the range hood in the dietary department, including replacing a cylinder and addressing welding and cleaning deficiencies.
K372: The facility failed to maintain smoke barrier walls to resist smoke passage, including a section of wall that came down exposing a penetration.
K712: The facility failed to ensure fire drills were conducted under varied conditions and maintain complete fire drill records, potentially affecting all residents.
Report Facts
Facility census: 43
Licensed capacity: 60
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 6
Date: Aug 2, 2019
Visit Reason
The inspection was conducted to assess compliance with resident rights, activities, quality of care, medication labeling, and environmental conditions at Apple Ridge Care Center.
Findings
The facility was found deficient in ensuring residents' voting rights, providing individualized activities, monitoring residents with pacemakers, managing mental health and behavioral concerns, and proper medication labeling and storage. Environmental conditions such as dust accumulation were also noted.
Deficiencies (6)
F550 Resident Rights: The facility failed to ensure residents who were able to vote and were registered were given the opportunity to vote during the election.
F679 Activities: The facility failed to individualize and provide structured activities after 1:30 P.M. to meet resident interests and needs for two sampled residents.
F684 Quality of Care: The facility failed to ensure physician's orders for monitoring a resident's pacemaker were documented and followed for one sampled resident.
F742 Treatment/Services Mental/Psychosocial Concerns: The facility failed to obtain a complete mental health summary upon re-admission and to update care plans for behaviors and psychosocial needs for one sampled resident.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure medications were stored, labeled, and dated correctly in two sampled medication rooms.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain ceiling fans and break room refrigerator free of dust and insects, affecting an unknown number of residents.
Report Facts
Facility census: 43
Residents with voting rights: 7
Residents participating in group meeting: 10
Sampled residents for activities: 14
Sampled residents with pacemaker: 14
Medication rooms sampled: 2
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 9
Date: Jul 11, 2018
Visit Reason
The inspection was conducted to identify deficiencies in compliance with federal and state regulations at Apple Ridge Care Center, including review of resident funds management, employee background checks, medication storage and administration, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to properly manage residents' personal funds, incomplete employee background and disqualification checks, improper medication storage and administration, inadequate food safety practices, and insufficient infection prevention and control measures. The facility census was consistently reported as 37 residents during the inspection.
Deficiencies (9)
F567: The facility failed to inform a resident in writing of increased surplus costs and obtain written authorization for expenditures from the resident's personal funds.
F569: The facility failed to notify residents receiving Medicaid benefits of certain balances and did not complete and send required Third Party Liability forms within 30 days of a resident's death.
F606: The facility failed to check the State Certified Nurse Aide Registry for federal indicators of abuse or neglect for newly hired employees prior to hiring.
F607: The facility failed to develop and implement abuse and neglect policies and procedures, including employee disqualification list checks for newly hired employees.
F761: The facility failed to ensure medications, including narcotics, were properly stored and not pre-set in medication cups prior to administration.
F803: The facility failed to ensure standardized recipes for pureed foods and proper food preparation to meet nutritional needs of residents on pureed diets.
F812: The facility failed to maintain proper food safety standards including refrigerator temperatures, cleanliness, and equipment maintenance.
F825: The facility failed to provide required specialized rehabilitative services, including restorative nursing care, as ordered for sampled residents.
F880: The facility failed to establish and maintain an infection prevention and control program, including proper hand hygiene facilities and housekeeping practices.
Report Facts
Facility census: 37
Employees hired since last survey: 16
Resident sample size: 12
Plan of correction completion dates: Multiple corrective actions planned for completion by 08/25/2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doris K. DeVault | Administrator | Signed the statement of deficiencies and plan of correction |
| Business Office Manager | Interviewed regarding resident funds and Third Party Liability forms | |
| Director of Nursing | DON | Interviewed regarding medication administration and employee background checks |
| Licensed Practical Nurse A | LPN | Observed administering medications and interviewed about medication practices |
| Dietary Manager | DM | Interviewed regarding food preparation and diet orders |
| Dietary Cook A | DC | Observed preparing pureed foods and interviewed about food safety |
| Maintenance Director | Interviewed regarding maintenance of handwashing sinks and soap dispensers | |
| Housekeeping Account Manager | Interviewed regarding housekeeping supplies and paper towels |
Inspection Report
Life Safety
Census: 37
Capacity: 60
Deficiencies: 10
Date: Jul 11, 2018
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
The facility failed to include transportation entities in its evacuation plan, had a wooden gate that did not open without obstruction, stored combustibles too close to a hot water heater, and failed to ensure proper inspection and maintenance of dampers in the ductwork. These deficiencies potentially affected multiple residents and staff.
Deficiencies (10)
E020 Policies and procedures. The facility failed to include transportation entities in the evacuation plan, affecting all residents and staff. The evacuation plan lacked contact information for transportation entities for use during evacuation.
K211 Means of Egress - General. The facility failed to ensure the wooden gate on the west hall opened without obstruction, potentially affecting at least 14 residents in one smoke zone.
K321 Hazardous Areas - Enclosure. The facility failed to ensure combustibles were stored at least three feet from the hot water heater in the East Hall mechanical room, potentially affecting 14 residents.
K500 Building Services - Other. The facility failed to ensure two dampers in the ductwork were exercised and inspected every four years per NFPA 105, potentially affecting all residents and staff in four smoke zones.
A2003 No Fire Hazard. The building presented a fire hazard as referenced in K321.
A2008 Hazardous Areas. Hazardous areas were not properly separated or protected as referenced in K321.
A2037 Exit Requirements. The lobby did not have at least a one-hour fire-rated separation from the remainder of the exiting floor as referenced in K211.
A3001 Substantially Constructed/Maintained. The building was not maintained in good repair as referenced in K321.
A4013 Policies/Procedures-Operational. The facility lacked policies and procedures to ensure residents' health and safety as referenced in E020.
A4015 Personnel Informed of Policies/Duties. Personnel were not fully informed of facility policies and duties as referenced in E020.
Report Facts
Facility census: 37
Licensed capacity: 60
Number of smoke zones affected: 4
Number of residents affected by wooden gate obstruction: 14
Number of residents affected by combustibles storage: 14
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