Cedar Ridge Center

In the surveyor’s words

From the most serious findings on record at Cedar Ridge Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jul 22, 2024

  Based on observations, resident and staff interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDRO's). Resident identifiers: #12, #17 and #72. Facility census: 110. On 07/18/24 at 3:51 PM an immediate jeopardy (IJ) was called at as this failed practice had the potential to affect all residents residing in the facility. Findings included: a) Resident #12 Resident #12 was admitted on [DATE]. Diagnoses included paraplegic, neurogenic bladder with suprapubic catheter, decubitus ulcers, vascular ulcers both heels, chronic kidney disease, and insulin dependent diabetic. […]

• Immediate jeopardy, patternF689May 14, 2025

  Based on observation and staff interview, the facility failed to ensure Resident #31, #37, #105 and #53 had an accident-free environment. Excessive gaps were found with no gap fillers at the foot of three (3) residents' beds. One (1) resident had his arm entrapped between the mattress and side rail. Excessive gaps in danger zones on a resident bed can lead to serious injuries including death. This created an immediate jeopardy situation that began on 05/13/25 at 10:00 AM and ended on 05/14/25 at 12:00 PM. Resident identifiers: #31, #37, #105 and #53. […]

• Immediate jeopardy, patternF689Apr 16, 2025

  Based on water temperature measurement and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The hot water temperature in the hand washing sink located in the main dining room was at an unsafe temperature for resident use. The water temperature in the hand sink in the main dining room was tested with facility equipment by the facility's maintenance director at approximately 2:30 PM on 04/16/25 the temperature was 139.2 degrees Fahrenheit. The water temperature in the sink in the main dining room at 2:56 PM was obtained in the same manner mentioned above and was 125 degrees Fahrenheit. […]

• Immediate jeopardy, patternF760Jul 22, 2024

  Based on record review and staff interview, the facility failed to ensure four (4) residents were free of significant medication errors. On 07/11/24, the facility reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman that Resident #69, Resident #74, Resident #39, and Resident #108 were administered their 8:00 AM medications twice due to incomplete medication administration documentation. The facility developed and implemented a plan of correction on 07/11/24. […]

• Immediate jeopardy, isolatedF600Mar 18, 2026

  Based on record review, staff interview and resident interview the facility failed to provide necessary safety to a resident who eloped the facility. Resident #18 eloped from the facility on 03/08/26 at approximately 9:00 AM. No action was taken by the facility until 1:30 PM, although a staff member seen Resident #18 walking down the street at approximately 9:00 AM. This neglectful practice placed Resident #18 in immediate risk for serious harm and or death. Resident identifier: #18 Facility Census: 113.The State Agency (SA) determined the facility's failure to act on a known elopement resulted in an Immediate Jeopardy situation when: staff witnessed Resident #18 walking down a public street at approximately 9:00 AM on 03/08/26 but failed to intervene or report the sighting. […]