Cherry Ridge

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF695Jul 29, 2026

  Based on observations, record reviews, and interviews, the facility failed to provide necessary care and services in accordance with the professional standards of practice for 2 (#1 and #78) of 2 residents reviewed for respiratory care. The facility failed to properly store a nebulizer mask, AutoPAP mask, and a nasal cannula when not in use.Findings: Review of the facility's Policy and Procedure for Respiratory Therapy – Prevention of infection revised November 2011 revealed the following in part: Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Steps in Procedure Infection Control Considerations Related to Oxygen Administration: 8. […]

• No harm, potential for more than minimal, patternF756Jul 29, 2026

  Based on record reviews and interviews, the facility failed to ensure the physician addressed irregularities identified by the pharmacist for 2 (#2 and #41) of 5 residents reviewed for unnecessary medications. The physician failed to provide a handwritten clinical rationale for the denial of a gradual dose reduction for Resident #2 and failed to address gradual dose reduction recommendations by the consultant pharmacist for Resident #41.Findings: Resident 2 Review of the medical record for Resident #2 revealed an admission date of 02/05/2026. Resident #2 had diagnoses that included traumatic subarachnoid hemorrhage, heart disease, muscle wasting and atrophy, depression, anxiety, hypothyroidism, and dementia. […]

• No harm, potential for more than minimal, patternF921Jul 29, 2026

  Based on observations and interviews the facility failed to provide a safe, sanitary, functional, and comfortable environment by having 1) a shower room and a storage closet room door unlocked on the secured unit, and 2) an air conditioner unit in a resident's room not properly secured to the wall for 1 (#6) of 4 residents reviewed for environment. Findings: Hall 1: On 07/27/2026 at 11:45 a.m., observation of the secured memory care unit revealed the door to the shower room and the storage closet were unlocked. Observation of the shower room revealed there were 2 one-gallon jugs of Dial hair and body soap (1 full and the other was 1/3 full) sitting on the shower chair in the shower. […]

• No harm, potential for more than minimal, patternF688Jun 4, 2025

  Based on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 2 (#73 and #23) of 3 (#73, #23, and #13) residents reviewed for positioning and mobility. Findings: Resident #23 Record review revealed Resident # 23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism of unspecified cerebellar artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and reduced mobility. Review of most recent quarterly Minimum Data Set (MDS) data revealed as Brief Interview of Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF759Jun 4, 2025

  Based on observations of the medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 5.26% medication error rate with 2 medication errors out of 37 opportunities. Findings: Resident #40 Observation of the medication pass for Resident #40 on 06/03/2025 at 7:15 a.m. revealed S3Licensed Practical Nurse (LPN) administered one eye medication, Dorzolamide 2%, 1 drop in each eye. Review of the physician orders for Resident #40 revealed an order for the glaucoma eye medication Brimonidine 0.2, 1 drop in both eyes three times daily at 8:00 a.m., 1:00 p.m. and 6:00 p.m. […]