Cedar Ridge Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three of eighteen residents (Resident #10, #37, and #81) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #10, #37, and #81's rooms were in a position that was accessible to the residents on 03/30/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to provide an activities program directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 85 of 85 residents. The facility's Activity Director was not a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. Findings Include: Record review on 04/01/2026 at 9:00 AM, of the facility's Administrative and other licensed professional staff licensure audit, revealed the current Activity Director was not certified. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of eighteen residents (Residents #1, #8, #18, #41, and #66) reviewed for medication storage. 1. The facility failed to ensure Resident #1 did not have a tube of zinc oxide inside his room on 03/30/2026. 2. The facility failed to ensure Resident #8 did not have a tube of zinc oxide and topical antibiotic ointment inside his room on 03/30/2026. 3. The facility failed to ensure Resident #18 did not have a tube of zinc oxide inside his room on 03/30/2026. 4. The facility failed to ensure Resident #41's eyedrops inside his room were not accessible to other residents on 03/30/2026. 5. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage, labeling, and dating. The facility failed to ensure all food items in the facility's kitchen were dated and discarded prior to their use-by date, were properly sealed, and failed to ensure the main ice machine was free of a brownish and blackish substance. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and 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 four of eighteen residents (Resident #5, #46, #67, and #82) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene before assisting the ADON on Resident #5's wound care on 04/01/2026. 2. The facility failed to ensure MA D sanitized the blood pressure cuff while administering medications to Residents #46 and Resident #67 on 03/31/2026. 3. The facility failed to ensure CNA E performed hand hygiene and changed his gloves during Resident #82's incontinent care on 03/30/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with wounds received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one of four residents (Resident #5) reviewed for quality of care. The facility failed to ensure that the interim ADON did not clean Resident #5's wound with the gauze used to clean the surrounding skin of the wound on 04/01/2026. This failure could place the residents with wounds at risk of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for one of five direct staff (LVN C) reviewed for accident hazard. 1. The facility failed to ensure LVN C did not leave a container of germicidal wipes on top of her cart unattended on 03/30/2026. 2. The facility failed to ensure there were no germicidal wipes on the ledge of the nurse's station, unattended, on 03/30/2026. These failures could prevent the residents from having an environment that was free from toxic chemicals.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #82) reviewed for incontinent care. The facility failed to ensure that CNA E performed the right technique during Resident #82's incontinent care on 03/30/2026. This failure could place the residents at risk of urinary tract infection.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for two of eighteen residents (Resident #33 and Resident #46) reviewed for pharmaceutical services. The facility failed to ensure LVN I did not leave Resident #33 and Resident #46's medications inside the cart on 03/31/2026, instead of administering their medications to them. This failure could place residents at risk of not receiving medications as ordered resulting in adverse effects such as worsening conditions and inadequate disease control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 4 residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) and nebulizer mouthpiece (device used to deliver medication in a mist form through the mouth) was properly stored when not in use on 09/30/2025. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect a left heel wound on 06/01/2025. These failures could place the residents at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #1) of four residents reviewed for Care Plans. The facility failed to ensure Resident #1's history of falls were care planned. This failure could place the resident at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #29, Resident #73, and Resident #82) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #29, Resident #73, and Resident #82's rooms were in a position that was accessible to the resident on 01/14/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (Rooms #1, #2, #3, #4, #5, and #6) of 10 resident rooms and the hallway floors reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' bed was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 4 (Resident #1, #5, #25, and #29) of 5 residents reviewed for physical restraints, The facility failed to obtain physician orders or a physician assessment as of 01/16/25 for Residents #1, #5, #25, and #29, for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free from any physical or chemical restraints.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #36, Resident #68, and Resident #79) of fifteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #36's care plan for catheter, dated 12/17/2024, had appropriate interventions. 2. The facility failed to ensure Resident #68's care plan for catheter, dated 10/02/2024, had appropriate interventions. 3. The facility failed to ensure Resident #79's care plan for catheter, dated 01/09/2025, had appropriate interventions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #16, #28, #40, and #38) of 14 residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #16's breathing mask for her nebulizer (machine that turns liquid medication into a mist breathed directly into the lungs) was properly stored when not in use on 01/14/2025. 2. The facility failed to ensure that Resident #28's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/14/2025. 3. The facility failed to ensure that Resident #40's nasal cannula was properly stored when not in use on 01/14/2025. 4. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure staff were wearing the appropriate hair and beard coverings. 2. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the date the product was received from the vendor. 3. The facility failed to ensure that the sugar and flour bins were cleaned. 4. The facility failed to ensure the ice scoop in the facility kitchen was cleaned. 5. The facility failed to ensure the food in the dry storage area was labeled with the product was received from the vendor. 6. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each residents environment remained as free from accident hazards as possible for 1 (Resident #30) of 9 residents reviewed for environmental hazards. The facility failed to ensure Resident #30 did not have pointed scissors in his room on 01/14/2024. This failure could place the resident and other residents who came into the room at risk for injury. Review of Resident #30's Face Sheet, dated 01/16/25, reflected that resident was an [AGE] year-old male initially admitted on [DATE]. Resident #30 had a diagnosis of dysphagia (difficulty swallowing) following other cerebrovascular disease (condition that impacts blood vessels in the brain). [...]

Inspectors wroteBased observation, interview and record review the facility failed to establish and 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 two (Resident #36 and Resident #39) of eight residents reviewed for Infection Control. 1. The facility failed to ensure CNA A and CNA B changed their gloves and performed hand hygiene while providing incontinent care to Resident #36 on 01/14/2025. 2. The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #39 on 01/14/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure confidential and personal medical records for two (Resident #1 and Resident #2) of two residents reviewed for privacy and confidentiality. 1. The facility failed to ensure RN A would close, lock, or minimize her laptop's monitor while administering medications to Resident #1 on 12/17/2024. 2. The facility failed to ensure RN A would close, lock, or minimize her laptop's monitor while providing wound care to Resident #2 on 12/17/2024. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals which could cause a loss of dignity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one cart (wound care cart) of five carts observed was kept locked or under direct observation of authorized staff in an area where residents could access it. The facility failed to ensure that RN A locked her wound care cart before providing wound care on 12/17/2024. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications.

Inspectors wroteBased observations, interviews, and record review, the facility failed to 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 one (Resident #3) of five residents reviewed for Infection Control. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #3 on 12/17/2024. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on record reviews and interviews, the facility failed to employ a certified Dietary Manager or a qualified fulltime dietitian or other clinically qualified nutrition professional for the facility's only kitchen. The facility failed to ensure the Dietary Manager met all required state guidelines or employed a full-time dietician, who also assisted in managing the facility kitchen's daily food and nutrition services. This failure could impact a resident's ability to receive acceptable and appropriated food and nutrition services.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 13 (Resident #'s 1, 4, 7, 10, 11, 18, 19, 22, 37, 43, 54, 59, and 69) of 27 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #'s 1, 4, 7, 10, 11, 18, 19, 22, 37, 43, 54, 59, and 69's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled ( labeled identifying items in the container) and dated ( the use by date was not documented) according to guidelines and in a sanitary manner. The facility failed to ensure damaged foods were discarded according to guidelines. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on interviews, and record reviews, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient needs for 1 of 3 residents (Resident #59) reviewed for hospice services. The facility failed to ensure Resident #59's hospice care was care planned. This failure could place residents at risk of needs not being met.

Inspectors wroteBased observation, interview, and record review, the facility failed to 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 2 (Resident #20 and Resident #39) of 4 residents reviewed for incontinence care. 1. The facility failed to ensure CNA B performed hand hygiene while providing incontinence care to Resident #20. 2. The facility failed to ensure CNA C performed hand hygiene while providing incontinence care to Resident #39. This failure could place residents at risk of cross-contamination resulting in infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 1 of 3 residents (Resident #8) reviewed for quality of life. The facility failed to provide Residents #8 with routine showers. These failures could place residents at risk for and a decreased quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to provide an environment that was free from accident and hazards to prevent accidents for 1 (Resident #10) of 6 residents reviewed for accidents free of hazards. The facility failed to ensure Resident #10 had a smoking assessment completed since admission to the facility on [DATE]. This failure placed the residents at risk of accidents and hazards. Findings Included: Record review of Resident #10's Face Sheet, dated 11/30/23, revealed she was an 89 -year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting and atrophy, mild cognitive impairment, and lack of coordination. Record review of Resident #10's MDS dated [DATE] revealed the resident's BIM was 05 (Severe Cognitive Impairment). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #13) reviewed for nutrition and hydration. The facility failed to assess Residents #13's weight on a weekly basis per the resident's care plan and the resident experienced an 11% weight loss in a 3-month period. This failure could place resident at risk of experiencing a decline in health due to malnutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 (Residents #2) of 4 residents reviewed for ADL's. 1. The facility failed to ensure Resident #2 was getting assistance with changing her brief and catheter care as needed. This failure had the potential to affect residents by placing them at risk for skin breakdown and a decline in their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of three residents observed for infection control. CNA A failed to ensure Resident #1's Foley catheter did not pull or hang from the resident during incontinence care. This failure could place residents at risk for infection and or trauma at the catheter site.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 one (Resident #1) of three residents observed for infection control. CNA A failed to perform hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for spread of infection through cross-contamination.