Cedar Ridge Inn

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 27, 2025

  Based on interview and record review, the facility failed to prevent the worsening of a pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin)for 1 (R #10) of 3 (R #10, #12 and #13) residents when staff failed to notify the physician when the resident's right gluteal fold (buttocks) wound worsened. If the facility does not recognize and notify the physician when a wound deteriorates, then the wound may worsen, become infected, and result in hospitalization. The findings are: A. […]

• Actual harm, isolatedF686Dec 1, 2023

  Based on interview and record review, the facility failed to properly care for a pressure ulcer (an injury that breaks the skin and underlying tissues) for 1 (R #195) of 6 (R #9, R #16, R #35, R #40, R #194, and R #195) residents randomly sampled for pressure ulcer, when they failed to do the following: 1. Monitor redness before it became a pressure wound. 2. Implement preventative interventions including pressure relieving devices 3. Delay in initiating wound care treatment for 11 days upon the discovery of (2) wounds. 4. Not consistently treating the wound with ointment as ordered. These deficient practices likely resulted in the development of unstageable wound with infection requiring hospitalization . The findings are: A. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2026

  Based on observation, record review, and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: Food items in the kitchen dry storage were not expired.Food items in the resident-use refrigerator (facility refrigerator designated for storing resident food and beverage items brought in from outside the facility) were not expired. The kitchen food preparation, food service, clean dishes storage, and ice machine areas were free from dust accumulation.This deficient practice is likely to affect all 82 residents identified on the resident census list provided by the Administrator on 06/01/26 and is likely lead to foodborne illnesses in residents if food is not being stored properly, and clean kitchen practices are not followed.The findings… […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2025

  Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manner for all residents who received food or drinks in the facility when staff failed to: - Keep the kitchen dust and grime free. - Ensure the ice machine drained through an air gap. These failures had the potential to result in cross-contamination and foodborne illness which could affect all residents who ate food from the kitchen. The findings are: Dust A. On 02/17/25 at 12:25 pm, observation of the kitchen revealed the following: - The wall and ceiling above the food preparation area were visibly dusty. - The deep fry area had visible dust and grime on it. - Vents near the food preparation area had dust and grime. […]

• No harm, potential for more than minimal, widespreadF761Dec 1, 2023

  Based on observations, interviews, and record reviews the facility failed to: 1. Ensure that opened insulin flex pen (pre-filed with insulin) were dated as to when they were opened by nursing staff. 2. Ensure expired supplies were not stored with unexpired supplies. 3. Document daily medication temperatures for refrigerator in medication room and medication carts, and medication room internal temperatures daily. These deficient practices could likely to result in all 89 residents that were identified on the census list provided by the Executive Director (ED) on [DATE] to receive expired or improperly temperature-controlled medications that have either lost their potency or effectiveness. The findings are: Findings for Opened insulin flex pen A. […]