Cedar Ridge Village

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to provide the required beneficiary notifications to residents upon discharge for 1 of 3 residents sampled (Resident #50). The facility reported a census of 38.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to ensure staff documented non-pharmacological interventions attempted prior to the administration of anti-anxiety medication (AA) for one of five residents reviewed for unnecessary medications (Resident #35). The facility reported a census of 38 residents. Findings Include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 admitted to the facility on [DATE] and had diagnosis of anxiety disorder. The MDS revealed the resident took an antianxiety (AA) medication during the seven day look-back period. The MDS recorded the resident had no behaviors. The Care Plan revised 4/23/25 lacked information related to Resident #35 taking an AA medication and the non-pharmacological interventions used or attempted prior to administration of the AA medication. [...]

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to ensure that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for 2 of 5 residents investigated for unnecessary medications (Resident #21 and #35). The facility reported a census of 38.

Inspectors wroteBased on clinical record review, observations, resident interview, staff interviews, and policy review, the facility failed to ensure staff appropriately completed a resident assessment and provide timely intervention for one resident with Lower Extremity Edema ([NAME]) for 1 of 1 resident reviewed for edema (Resident #21) and 1 of 4 residents sampled for skin conditions (Resident #1). The facility reported a census of 38.

Inspectors wroteBased on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to follow care planned interventions to prevent and mitigate falls for 1 of 3 residents sampled (Resident #6). The facility reported a census of 38.

Inspectors wroteBased on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure safe and accurate delivery of oxygen therapy for one of two residents reviewed for respiratory care (Resident #21). The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review, the facility failed to utilize enhanced barrier precautions (EBP's) and infection control practices for 1 of 4 residents sampled on EBP's (Resident #34). The facility also failed to ensure staff followed infection control practices to protect against cross-contamination and potential spread of infection for a resident on droplet precautions for 1 of 4 residents on droplet/contact precautions (Resident #4). The facility reported a census of 38 residents.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure open items were dated, covered and labeled. The facility further failed to ensure potentially hazardous food items were stored separately; thawing meat was stored above other food items in the refrigerator. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, staff interview and facility policy review, the facility's Dietary Staff failed to perform the proper functions of food and nutrition services for the pureed food process for 3 of 3 residents requiring a pureed diet. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to serve food under sanitary conditions by touching the prepared food with their bare hands and the eating surface of the plates during meal service. The facility reported a census of 31 residents.

Inspectors wroteBased on personnel file review, facility record review, facility policy review, and staff interview the facility failed to complete the background record check evaluation process for a new employee, prior to employment, for 1 of 5 staff reviewed (Staff K, Certified Nurse Aide CNA). The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to complete an accurate assessment for a resident with a Preadmission Screening and Resident Review (PASRR) condition for one of one resident reviewed (Resident #12).

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to refer a resident to the appropriate state-designated authority for a Level I Status Change Preadmission Screening and Resident Review (PASRR) evaluation and determination for a resident with a documented PASARR condition and an exempted hospital discharge 30-day approval for one of one resident reviewed (Resident #12).

Inspectors wroteBased on resident and family interviews, clinical record review, policy review and staff interview, the facility failed to provide care plan conferences to enable resident/family participation in two (Resident ##17 and Resident #22) of two residents reviewed.

Inspectors wroteBased on clinical record review, family interview, and staff interview, the facility failed to have a restorative program and provide restorative services for one (Resident ##17) of one resident reviewed.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance committee (QAA) was attended by the required members to include: 1) the Nursing Home Administer (NHA) or representative; 2) Director of Nursing (DON); 3) the Medical Director (MD) or representative; 4) the Infection Preventionist; and 5) two other members of the facility's staff present on a minimum of a quarterly basis. The facility reported a census of 31.

Inspectors wroteBased on observations, staff interview, clinical record review, and policy review the facility failed to implement appropriate infection control practices to prevent cross contamination. In addition, the facility failed to perform on-going infection control surveillance. The facility reported a census of 31 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to designate a qualified Infection Preventionist responsible for the facility's Infection Control and Prevention program. The facility reported a census of 31 residents.