Cedar Ridge Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, and sanitary environment for 2 of 4 days of survey (4/13/26 and 4/14/26).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that during the regulatory visit, the Provider reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the physician block orders for 5 of 5 residents reviewed for unnecessary medications (Residents #7 [R7]), R59, R5, R14, R33).

Inspectors wroteBased on observation and interviews, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 4 days of survey (4/13/26). In addition, the facility failed to prepare food under sanitary conditions for 1 of 4 days of survey (4/14/26).

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain an infection control program to help prevent the spread of infection related to pressure ulcer treatment for 1 of 2 residents observed for a pressure ulcer dressing change (Resident #55 [R55]. On 4/13/26, a review of R55's clinical record was completed. Documentation indicated R55 has a Stage 3 pressure ulcer on the left heel. Documentation in the physician orders indicated that the pressure ulcer treatment is to cleanse the wound with wound cleanser, apply a medihoney dressing to the wound bed and cover with a foam border once a day and as needed. On 4/14/26 at 6:50 a.m., a pressure ulcer dressing change observation was completed with RN1 performing the dressing change. Initially RN1 donned clean gloves, and set up a clean work field at the foot of the bed. [...]

Inspectors wroteBased on interviews, review of the facility's filed grievances, and record review, the facility failed to implement parts of its Grievance/Concern policy and procedure for 1 of 2 residents that filed grievances (Resident #44 [R44]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an as needed (PRN) psychotropic medication was ordered for 14-days or less unless there is a practitioner's rationale for PRN use beyond 14-days for 1 of 5 residents reviewed for unnecessary medications (Resident #59 [R59]).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 2 sampled residents reviewed for PASRR (Resident #1 [R1]).

Inspectors wroteBased on clinical record reviews and interviews, the facility failed to ensure physician orders were followed for blood pressure parameters prior to administering a medication for 1 of 5 resident's reviewed for unnecessary medications (Resident #7 [R7]) and failed to follow physician's orders by holding a medication that was ordered for 1 of 5 resident's reviewed for unnecessary medications (R59).

Inspectors wrote10. On 6/3/25 at 10:00 a.m., in an interview with a surveyor, Resident #10 stated that he/she had asked to use the bedpan at approximately 2:10 am this morning. They came and put me on it and I rang again when I was finished. No one came until 7 or 8 o'clock this morning. I ended up taking it out and it fell off the bed when I moved. The nurse was the one who found it. On 6/3/25 at 1:20 p.m., in an interview with a surveyor, the RN confirmed that he/she had found Resident #10's bedpan spilled on the floor and had to clean it up. He/she stated there had been no CNA from 6 a.m. to 8 a.m. on the unit and he/she was doing both jobs as the CNA and the nurse on the Blue Spruce unit. On 6/3/25 at 1:30 p.m., the finding was discussed with the Director of Nursing. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure equal access to services, including assistance with alternative placement, when the payor source changed from Medicare Part A to private pay for 1 of 1 residents reviewed for discharge.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of Post-Traumatic Stress Disorder(PTSD)/trauma for 3 of 4 sampled residents reviewed for PTSD. (#1, #5, #51)

Inspectors wroteBased on observations and interviews, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 days of survey. (1/27/25, 1/28/25 and 1/29/25)

Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).

Inspectors wroteBased on record review, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 4 of 4 units reviewed (Hickory, Elm, Blue Spruce and Scotch Pine) and failed to maintain adequate pharmaceutical services to ensure the receipt and administration of physician ordered medication was available to meet the needs of a resident requiring intravenous antibiotics (Resident #329).

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. Additionally, the facility failed to ensure foods were sealed, labeled, and dated in a dry storage room, a walk-in freezer and a walk-in refrigerator, as well as failed to ensure the emergency food supply was not stored with unsecured chemicals for 1 of 3 days of survey (1/27/25). Furthermore, the facility failed to ensure that the Dish Machine temperatures, Refrigerator temperatures, and Freezer temperatures were monitored for 3 of 3 months reviewed.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly communicated to the residents or their representatives for 4 of 5 residents reviewed for Arbitration (Resident #35, #46, #57, #331).

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for residents requiring Enhanced Barrier Precautions (Residents #327 and #331) on 1 of 5 facility units.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide care to residents in a manner that maintains each resident's dignity by failing to serve all residents seated at the same table at the same time for 1 of 2 dining observations on 1 of 1 days of survey.

Inspectors wroteBased on record review and interviews the facility failed to appropriately notify a resident and or resident representative in a timely manor, prior to changing a residents room, for 1 of 1 residents reviewed for room change. On 1/21/25 the Division of Licensing and Certification received a complaint in regards to a resident's room being changed without proper notification. On 1/27/25 at 8:00 p.m., during an interview Resident #57 and his/her family member both stated that they had not received any notification of a room change prior to it occurring. Review of Resident #57's clinical record indicates that the resident was moved from Elm Unit to Hickory Unit on 1/15/25. Further review of the clinical record lacked evidence that any notification of the room change occurred. On 1/30/25 at 2:31 p.m., during an interview with the Market Clinical Advisor the above information was confirmed.

Inspectors wroteBased on interview and record review, the facility failed to review, revise and update a care plan in the area of Post-Traumatic Stress Disorder (PTSD) for 1 of 4 residents whose care plans were reviewed for PTSD. (#18)

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to demonstrate evidence of behavior monitoring and monitoring for side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (#26).

Inspectors wroteBased on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 4 units observed for medication storage. (Scotch Pine House)

Inspectors wroteBased on facility policy review, record reviews, and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, was completed for 8 of 16 residents reviewed for advanced directives. (Resident #5, #61, #27, #51, #26, #31, #474 and #325).

Inspectors wroteBased on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 3 residents reviewed during a complaint investigation (Resident #1).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for wounds (Resident #1).

Inspectors wroteBased on facility policy review, interview and record review the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering excessive doses of Ativan in less than 7 hours and failed to monitor of psychotropic medication side effects for 1 of 9 sampled residents (#7).

Inspectors wroteBased on the facility's Falls Management policy, interviews and record review the facility failed to ensure that a resident's physician and/or representative were notified immediately of an unwitnessed fall and failed to follow its own policy and procedure for unwitnessed falls for 1 of 9 residents reviewed for falls. (#1)

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 9 residents reviewed. (#7)

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a care plan was followed for a 2 assist transfer for 1 of 4 sampled residents requiring a mechanical device use for a transfer and failed to ensure the care plan was accurate to reflect the residents advanced directive code status. (Resident #7)

Inspectors wroteBased on interview, observation and record review, the facility failed to revise the care plan to reflect a resident's current status for 1 of 2 residents reviewed for infection prevention and control (#1).

Inspectors wroteBased on facility policy, observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to oxygen and nebulizer use for 2 of 2 residents reviewed for respiratory care. (Resident #4 and #6)

Inspectors wroteBased on record review and observation, the facility failed to ensure the Treatment Administration Record (TAR) was accurately documented for changing of oxygen tubing for 1 of 2 residents reviewed for oxygen use (#6).

Inspectors wroteBased on record review, interviews and observations the facility failed maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 day of survey.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that a resident's bed was maintained in good repair and safe operating condition for 2 of 2 observations for 1 of 1 day of survey. (9/3/24)

Inspectors wroteBased on observations and interviews the facility failed to promote care for resident in a manner that maintains the resident's dignity by allowing an uncovered urine filled Foley catheter bag to be seen by passersby for 1 of 3 residents (Resident #9) observed for dignity related to urinary collection bags during 1 of 2 days of survey (5/7/24).

Inspectors wroteBased on observations, interview, record review, and facility policy the facility failed to complete a Self-Administration of Medication Assessment for 1 of 4 resident reviewed for medication administration. (Resident #1)

Inspectors wroteBased on record reviews and interviews, the facility failed to update/implement goals and interventions for 3 of 9 care plans reviewed (Resident #1, #4 and #6).

Inspectors wroteBased on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 2 sampled residents (Resident #6).

Inspectors wroteBased on record review and interviews, the facility failed to monitor and document targeted behaviors to support the use of an antipsychotic and antianxiety medication for 1 of 2 residents reviewed for unnecessary medications (Resident #6).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition on 3 of 5 Units (Elm, Blue Spruce, and [NAME]) for 1 of 1 Environmental Tour.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food mixer, a food slicer, ceiling vents, and ceiling tiles. Additionally, the facility also failed to date, label and/or seal foods in the dry storage area, the reach-in refrigerator, the walk-in refrigerator and the walk-in freezer.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop a discharge plan that focused on resident discharge goals, preparation, and effective transition of care for 3 of 24 sampled residents (Resident #64, #71, and #375).

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that Oxygen was administered according to physician's orders for 2 of 2 days (#20).

Inspectors wroteBased on observation and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 3 dumpsters for 1 of 4 days of survey. (6/12/22)