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 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.

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.

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 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.

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 visit was complaint-related due to allegations of abuse involving three residents. The complaint was substantiated as the facility failed to prevent abuse incidents.

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.

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 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.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.