Inspection Reports for
Cedar Ridge Inn
800 SAGUARO TRAIL, FARMINGTON, NM, 87401
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to prevent the worsening of a pressure ulcer in one resident and failure to secure an oxygen cylinder to prevent accidents.
Complaint Details
The complaint investigation found that the facility failed to notify the physician about the worsening pressure ulcer of resident #10, which led to infection and hospitalization. The wound care nurse and staff failed to communicate changes timely. The Director of Nursing and Medical Director acknowledged the failures. Additionally, the facility failed to secure an oxygen cylinder for resident #13, creating a safety hazard.
Findings
The facility failed to notify the physician about the deterioration of a resident's pressure ulcer, resulting in actual harm and hospitalization. Additionally, the facility failed to secure an oxygen cylinder properly, posing a safety hazard.
Deficiencies (2)
Failure to prevent worsening of a pressure ulcer and failure to notify physician of wound deterioration.
Failure to secure an oxygen cylinder to prevent tipping and falling over.
Report Facts
Residents affected: 1
Residents affected: 1
Wound measurements: 5.6
Wound measurements: 3.31
Wound measurements: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Involved in wound care oversight and communication failures regarding resident #10's pressure ulcer |
| Nurse #3 | Nurse | Provided wound care for resident #10 and failed to notify physician or DON of wound deterioration |
| Wound Care Nurse | Wound Care Nurse | Provided wound care orders and was involved in wound care management for resident #10 |
| Medical Director | Medical Director | Acknowledged expectation to be notified of wound changes for resident #10 |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, environment, pharmaceutical services, dietary services, and kitchen sanitation at Cedar Ridge Inn nursing home.
Findings
The facility was found deficient in maintaining a homelike environment due to unrepaired water damage, unsafe wheelchair practices without foot pedals, delayed notification of lost controlled medication, failure to provide a resident's special dietary needs, and unsanitary kitchen conditions including dust accumulation and improper ice machine drainage.
Deficiencies (5)
Failure to repair water damage to the outdoor patio fascia and soffit, affecting the homelike environment.
Failure to use foot pedals when propelling residents in wheelchairs, creating potential accident hazards.
Failure to promptly identify and notify pharmacist consultant of lost controlled medication (lorazepam) for a resident.
Failure to provide a salt-free diet to a resident with special dietary needs, risking fluid buildup and complications.
Failure to maintain kitchen sanitation: dusty walls, ceilings, vents, and deep fry area; ice machine did not drain through an air gap.
Report Facts
Deficiencies cited: 5
Medication doses administered: 25
Medication tablets received: 60
Medication tablets remaining: 35
Fluid restriction: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA #1 | Certified Medication Aide | Counted and maintained medication accountability for lorazepam tablets |
| Nurse #1 | Nurse | Counted and maintained medication accountability for lorazepam tablets |
| Maintenance Director | Responsible for building maintenance and courtyard safety; aware of water damage and fence issues | |
| Administrator | Facility administrator interviewed regarding maintenance and safety issues | |
| COTA #1 | Certified Occupational Therapy Assistant | Provided information on wheelchair management and fall risk assessments |
| DON | Director of Nursing | Responsible for medication reconciliation and notification of missing controlled substances |
| Consultant Pharmacist | Pharmacist | Audited medication carts and expected timely notification of missing medication |
| Dietary Manager | Dietary Manager | Responsible for resident dietary needs and meal ticket information |
| Registered Dietician | Registered Dietician | Oversaw liberalized diet program and expected dietary needs to be met |
| Medical Director | Medical Director | Provided input on dietary management and resident preferences |
| Dietary Supervisor | Dietary Supervisor | Interviewed about kitchen sanitation and cleaning practices |
| Director of Maintenance | Director of Maintenance | Responsible for maintenance of ice machines and kitchen sanitation |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 1, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care standards related to blood glucose monitoring, PICC line flushing, and pressure ulcer care at Cedar Ridge Inn.
Findings
The facility failed to ensure qualified staff performed blood glucose monitoring and PICC line flushing, resulting in potential harm. Additionally, the facility inadequately managed a pressure ulcer for one resident, including delayed wound care and inconsistent treatment, leading to an unstageable wound with infection requiring hospitalization.
Deficiencies (2)
Failed to provide blood glucose monitoring and PICC line flushing by qualified nursing staff for residents #61 and #200.
Failed to provide appropriate pressure ulcer care for resident #195, including monitoring redness, implementing preventative interventions, timely wound care, and consistent ointment application.
Report Facts
Residents affected: 2
Residents sampled for pressure ulcer: 6
Residents affected by pressure ulcer deficiency: 1
Collagenase ointment doses not available: 16
Wound culture date: Oct 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed confirming CMAs were performing glucose readings and reporting incident of CNA flushing PICC line |
| Certified Medication Assistant #2 | Certified Medication Assistant | Observed performing glucose readings for residents #61 and #143 |
| Certified Nursing Assistant | Certified Nursing Assistant | Reported to have flushed PICC line outside scope of practice, suspended pending investigation |
| New facility Administrator | Administrator | Interviewed regarding pressure ulcer wound condition and care |
| Wound Care Nurse | Wound Care Nurse | Reported resident #195 often refused wound treatment, no longer employed at facility |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Dec 1, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided by the facility.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate accommodation of resident needs, failure to notify physicians of critical lab results, incomplete grievance documentation, improper blood glucose monitoring and PICC line flushing by unqualified staff, inadequate pressure ulcer care, poor pharmaceutical record keeping, unsafe food handling practices, incomplete and inaccurate medical records, lapses in infection prevention and control practices, and an incomplete antibiotic stewardship program.
Deficiencies (13)
Failed to treat residents with respect and dignity by not knocking or announcing before entering rooms.
Failed to reasonably accommodate residents' needs by not ensuring call lights were within reach.
Failed to notify physician of Vancomycin trough level not checked prior to next dose.
Failed to ensure grievance documentation included summaries of investigations and findings.
Failed to provide proper blood glucose monitoring and allowed unqualified staff to flush PICC line.
Failed to provide appropriate pressure ulcer care resulting in unstageable wound with infection.
Failed to maintain accurate controlled substance records with missing signatures on narcotic logs.
Failed to ensure drugs and biologicals were properly labeled, stored, and expired supplies removed.
Failed to ensure laboratory tests were completed as ordered and promptly reported.
Failed to serve food under sanitary conditions including undated food packages and improper handling.
Failed to maintain complete and accurate medical records and medication cards matching physician orders.
Failed to implement infection prevention and control program including improper handling of soiled linen and glucometer disinfection.
Failed to implement a comprehensive antibiotic stewardship program with incomplete documentation and tracking.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 19
Residents affected: 2
Residents affected: 6
Residents affected: 89
Residents affected: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in failure to notify physician of Vancomycin trough level lab not drawn |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding expectations and deficiencies |
| Medical Director | Medical Director | Interviewed regarding notification of lab results and medication orders |
| Certified Medication Assistant #2 | Certified Medication Assistant | Named in blood glucose monitoring and narcotic log deficiencies |
| Certified Medication Assistant #1 | Certified Medication Assistant | Named in glucometer disinfection deficiency |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed missing narcotic log signatures and expired supplies |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Observed transporting soiled linen improperly |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Observed transporting soiled linen improperly |
| House Keeper #1 | House Keeper | Interviewed about laundry PPE use |
| Dietary Manager | Dietary Manager | Interviewed about food handling and labeling deficiencies |
| Certified Medication Aide #3 | Certified Medication Aide | Observed improper handling of drinks in dining room |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed improper handling of dessert bowls in dining room |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, activities, respiratory care, medication administration, drug labeling, dining assistance, and environmental safety at Cedar Ridge Inn nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain updated and physician-signed advanced directives for residents, inadequate individualized activities, improper labeling and dating of oxygen tubing and humidifier bottles, medication errors exceeding 5 percent, unlabeled insulin vials, lack of assistive eating utensils for a resident, and unsafe air pressure conditions in the clean linen laundry area.
Deficiencies (7)
Failed to maintain updated and valid advanced directives with physician signatures for 5 residents.
Failed to provide ongoing individualized activities meeting residents' interests for 2 residents.
Oxygen tubing not dated when changed for 5 residents and humidifier bottles not labeled for 1 resident.
Medication error rate exceeded 5 percent with 2 errors out of 30 opportunities, including failure to aspirate PICC line and administration of discontinued medication.
Insulin vials were not properly labeled with resident identification.
Failed to provide assistive eating utensils (built-up fork) for 1 resident during meal.
Clean linen laundry area had negative air pressure allowing air flow from hall into clean linen storage, risking contamination.
Report Facts
Residents affected: 5
Residents affected: 2
Residents affected: 5
Medication errors: 2
Medication error rate: 6.67
Residents affected: 1
Residents affected: 1
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error findings for failure to aspirate PICC line and administration of discontinued medication |
| Director of Nursing | Director of Nursing | Interviewed regarding advanced directives and oxygen tubing procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication administration procedures |
| Registered Nurse #1 | Registered Nurse | Confirmed insulin vials were not properly labeled |
| Activities Director | Activities Director | Interviewed regarding resident activities program |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed unlabeled oxygen tubing and humidifier bottle |
| Dietary Manager | Dietary Manager | Confirmed resident was not provided assistive eating utensils |
| Housekeeping Manager | Housekeeping Manager | Confirmed air flow into clean linen laundry area |
Viewing
Loading inspection reports...
