Cedar Ridge Health Campus

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Feb 9, 2024

  Based on observation, interview, and review of the facility's policies, it was determined the facility failed to prepare and store food under sanitary conditions. Observation of the kitchen on [DATE] revealed staff did not perform hand hygiene between glove changing and tasks. Observation of the Skilled nourishment room on [DATE] revealed non-food items stored with food items and undated food items. The findings include: Review of the facility's policy titled Guideline for Handwashing/Hand Hygiene, dated [DATE], revealed all health care workers shall utilize hand hygiene frequently and appropriately. Per the policy, hand hygiene should be performed after removing gloves, with gloves worn as directed with Standard Precautions; before and after eating; and after toileting. […]

• No harm, potential for more than minimal, isolatedF583Jan 22, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to privacy by allowing a video camera to be installed, which actively monitored a resident's room without documented consent or adherence to facility policy for 1 of 2 residents reviewed for dignity, Resident (R) 3. The findings include: Review of the facility's policy titled, Resident Electronic Monitoring SOP [Standard Operating Procedure], undated, revealed, The resident, attorney-in-fact, or guardian must authorize the installation and use of the device for remote monitoring on our standard authorization form. […]

• No harm, potential for more than minimal, isolatedF759Jan 22, 2026

  Based on observation, interview, record review, review of the manufacturer's instructions for use, and facility policy review, the facility failed to ensure a medication error rate of 5 percent (%) or less. Observation on 01/22/2026 revealed 2 errors administering insulin (given to lower blood sugar) out of 27 opportunities observed for correct medication administration, which yielded a medication error rate of 7.41%. The errors affected 2 of 5 residents observed for medication administration, Resident (R) 11 and R23.The findings include: Review of the facility's policy titled, Medication Administration - General Guidelines, revised 11/2018, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized… […]

• No harm, potential for more than minimal, isolatedF656Jan 24, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for each resident to meet his or her preferences and goals for 1 of 14 sampled residents (Resident (R) 6). Observation of R6 on 01/22/2025 at 9:02 AM and again on 01/23/2025 at 9:00 AM revealed an Occupational Therapist (OT) assisting the resident with application of a left arm splint. During interviews with staff and R6, it was determined the splint was a resident preference worn at her discretion and not a recommendation of the facility. However, the resident's preference was not included in her comprehensive care plan. […]

• No harm, potential for more than minimal, isolatedF812Jan 24, 2025

  Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Observation on [DATE] of the shared nourishment refrigerator and freezer for the 100, 200, and 300 Units revealed multiple food items that were not labeled or dated. The findings include: Review of the facility's policy titled, Food Brought Into Facility, dated [DATE], revealed food brought in by family members, friends, or guests must be properly labeled and dated after being inspected by a staff member that had been properly trained to receive and inspect food. […]