Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 28, 2025
Visit Reason
The document is a plan of correction submitted by Cedar Ridge Village following a prior inspection, indicating acceptance of substantial compliance and outlining corrective actions.
Findings
The facility is certified in compliance effective August 26, 2025, based on acceptance of the credible allegation of substantial compliance and the submitted plan of correction.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of credible allegation of substantial compliance and plan of correction. |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 7
Aug 12, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #2582089-C from August 4 to August 12, 2025.
Findings
The survey identified multiple deficiencies related to Medicaid/Medicare coverage notifications, chemical restraint use, psychotropic drug administration, comprehensive care planning, quality of care including skin assessments and fall prevention, respiratory care, infection control, and documentation practices. The facility failed to meet several federal requirements and implemented corrective actions with specified compliance dates.
Complaint Details
Complaint #2582089-C was investigated during the annual recertification survey but did not result in a deficiency.
Deficiencies (7)
| Description |
|---|
| Failure to provide required Medicaid/Medicare beneficiary notifications upon discharge for sampled residents. |
| Residents' right to be free from chemical restraints not fully ensured; lack of documentation of non-pharmacological interventions prior to administration of PRN anti-anxiety medication. |
| Comprehensive care plans not developed or implemented for residents receiving unnecessary medications; lack of measurable objectives and timelines. |
| Quality of care deficiencies including failure to complete timely resident assessments and monitor lower extremity edema and skin conditions. |
| Failure to ensure resident environment free from accident hazards; inadequate supervision and interventions to prevent falls. |
| Respiratory care deficiencies including failure to ensure safe and accurate oxygen therapy for residents needing respiratory support. |
| Infection prevention and control program deficiencies including failure to implement enhanced barrier precautions and infection control practices for residents with communicable diseases. |
Report Facts
Census: 38
Deficiencies cited: 7
Dates of Compliance: Aug 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to acknowledging notification deficiencies, care plan updates, audits, and corrective actions. |
| MDS Coordinator | Minimum Data Set (MDS) Coordinator | Named in relation to auditing, care plan updates, and documentation of notifications and interventions. |
| Staff G | Registered Nurse (RN) | Interviewed regarding medication administration and documentation. |
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and observations. |
| Staff B | Registered Nurse (RN) | Interviewed regarding oxygen therapy and resident care. |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding resident isolation and care. |
| Staff E | Certified Nursing Assistant (CNA) | Observed and interviewed regarding infection control and resident care. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding infection control practices. |
| Staff H | Licensed Practical Nurse (LPN) | Interviewed regarding resident care and medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 2025
Visit Reason
A complaint investigation for complaints #125897-C and #125937-C was conducted from April 7, 2025 to April 8, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint investigation for complaints #125897-C and #125937-C; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 17, 2024
Visit Reason
A complaint investigation was conducted for facility reported incident #123066-I from December 16, 2024 to December 17, 2024.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation related to incident #123066-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 16, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of a credible allegation of compliance and plan of correction for certification.
Findings
The facility will be certified in compliance effective August 16, 2024, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Aug 1, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and included investigation of multiple complaints and facility-reported incidents between July 29, 2024 and August 1, 2024.
Findings
The facility was found deficient in meeting nutritional needs and food safety requirements. Specifically, the dietary staff failed to properly perform the pureed food process for residents requiring pureed diets, and the facility failed to ensure proper dating, labeling, and storage of food items, including hazardous foods stored improperly in the refrigerator.
Complaint Details
The inspection included investigation of Complaints #118825-C, #119569-C, and Facility Reported Incident #121248-I.
Deficiencies (2)
| Description |
|---|
| 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. |
| Facility failed to ensure open food items were dated, covered, and labeled, and failed to ensure potentially hazardous food items were stored separately with proper thawing procedures. |
Report Facts
Census: 40
Residents requiring pureed diet: 3
Food items observed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Cook | Observed performing pureed food process incorrectly |
| Staff B | VP of Culinary | Provided guidance on proper pureed food preparation and recipe adherence |
| Dietary Manager | Dietary Manager | Present during observation of food storage deficiencies and interviewed |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 22, 2024
Visit Reason
The document is a plan of correction following a credible allegation of substantial compliance for Cedar Ridge Village Nursing Home.
Findings
The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and will be certified in compliance effective December 29, 2023.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 9
Dec 11, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint intakes #115287-C and #116638-I.
Findings
The facility was found non-compliant with multiple federal regulations including failure to complete background checks prior to employment, inaccurate resident assessments, failure to complete PASRR screenings, lack of care plan conferences with residents/families, failure to provide restorative services, improper food handling practices, incomplete Quality Assurance and Assessment committee attendance, inadequate infection prevention and control practices, and lack of a qualified infection preventionist.
Complaint Details
Complaint #115287-C was unsubstantiated. Facility reported incident #116638-I was unsubstantiated.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to complete background record check evaluation process for a new employee prior to employment. | — |
| Failed to complete an accurate Minimum Data Set (MDS) assessment for a resident with a PASRR condition. | SS=D |
| Failed to refer a resident to the appropriate state-designated authority for a Level I PASRR evaluation and determination. | SS=D |
| Failed to provide care plan conferences to enable resident/family participation for two residents. | SS=D |
| Failed to have a restorative program and provide restorative services for one resident. | SS=D |
| Failed to serve food under sanitary conditions by touching prepared food and eating surfaces with bare hands during meal service. | SS=E |
| Quality Assessment and Assurance committee meetings lacked attendance by required members including the Administrator, Director of Nursing, Medical Director, and Infection Preventionist. | SS=D |
| Failed to implement appropriate infection control practices to prevent cross contamination and failed to perform ongoing infection control surveillance. | SS=D |
| Failed to designate a qualified Infection Preventionist responsible for the facility's Infection Prevention and Control program. | SS=D |
Report Facts
Deficiencies cited: 9
Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Certified Nurse Aide | Named in deficiency for failure to complete background check prior to employment. |
| Malinda Swetter | Executive Director | Signed the Statement of Deficiencies and Plan of Correction. |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 16, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective August 30, 2023.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Aug 7, 2023
Visit Reason
The inspection was conducted due to substantiated complaints #114599-C and #106997-I, investigating allegations of abuse, neglect, exploitation, or mistreatment related to bruises and skin issues of unknown origin in residents.
Findings
The facility failed to thoroughly investigate bruises and skin issues of unknown origin for 2 of 3 residents reviewed. Documentation lacked explanations or investigations of the bruises. Additionally, the facility failed to have the Medical Director attend the required quarterly Quality Assessment and Assurance (QA) Committee meeting.
Complaint Details
Complaint #114599-C was substantiated based on the facility's failure to investigate bruises and skin issues for residents #2 and #3.
Severity Breakdown
SS=D: 1
SS=B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate bruises and skin issues of unknown origin for residents #2 and #3. | SS=D |
| Failed to have the Medical Director attend the June quarterly Quality Assessment and Assurance Committee meeting. | SS=B |
Report Facts
Total residents: 32
Date survey completed: Aug 7, 2023
Date correction: Aug 30, 2023
Quality Assurance Meeting date: Jun 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reported lack of documentation and investigation of bruises for Resident #3 | |
| Administrator | Acknowledged concerns with lack of investigation of bruises on residents | |
| Staff A | Registered Nurse | Documented some incidents but unaware of others related to bruising on residents |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 13, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective August 30, 2022.
Inspection Report
Annual Inspection
Census: 17
Deficiencies: 6
Jul 20, 2022
Visit Reason
The inspection was the facility's annual health survey conducted from 7/17/22 to 7/20/22 to assess compliance with federal regulations.
Findings
The facility was found deficient in multiple areas including failure to provide 48-hour notice before discharging residents allowing appeal, failure to notify the Long-Term Care Ombudsman of resident hospital transfers, failure to provide bed hold notifications, failure to complete monthly drug regimen reviews by a licensed pharmacist, failure to properly secure and date food items and maintain food service hygiene, and failure to provide adequate perineal care to an incontinent resident.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide 48-hour notice before discharging residents from skilled nursing facility services allowing them the chance to appeal the discharge. | SS=D |
| Failed to notify the Long-Term Care Ombudsman of a resident's transfer to the hospital. | SS=D |
| Failed to provide Bed Hold notification to a resident or their responsible party before hospital transfer. | SS=D |
| Failed to complete monthly drug regimen reviews by a licensed pharmacist for three residents. | SS=D |
| Failed to prepare and serve food in accordance with professional standards for food service safety by failing to secure and date food items and improper glove use during meal service. | SS=D |
| Failed to provide adequate perineal care on an incontinent resident, including improper use of washcloths and failure to perform hand hygiene between contaminated and clean tasks. | SS=D |
Report Facts
Residents sampled: 3
Census: 17
Medication Regimen Reviews missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Observed providing inadequate perineal care to Resident #3. |
| Staff C | Licensed Practical Nurse | Reported expectations for glove use and hand hygiene during care. |
| Staff D | Dietary Aide | Observed improper glove use and food handling during meal service. |
| Director of Nursing | Verified failures in notification processes and expectations for care and infection control. | |
| Assistant Director of Nursing | Provided explanations regarding notification and discharge processes. | |
| Administrator | Acknowledged notification failures and policy gaps. | |
| Consulting Pharmacy Supervisor | Confirmed pharmacist responsibilities for monthly medication reviews. | |
| Consulting Pharmacist | Reported plans to submit missing medication regimen reviews. | |
| Dietary Manager | Reported concerns about glove use and conducted kitchen audits. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 19, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility was certified in compliance effective May 4, 2022, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
May 2, 2022
Visit Reason
The inspection was conducted as an investigation of Complaint #104402 regarding alleged abuse at Cedar Ridge Village from 5/2/22 to 5/3/22.
Findings
The facility failed to report an allegation of abuse involving Resident #3 to the Department and submit an investigation within 5 days. The complaint was substantiated based on clinical record reviews, resident and staff interviews, revealing staff communication and protocol deficiencies.
Complaint Details
Complaint #104402 was substantiated. The facility did not report an allegation of abuse involving Resident #3 within the required timeframe and failed to submit an investigation within 5 days of the incident.
Deficiencies (1)
| Description |
|---|
| Failure to report alleged abuse and submit investigation within required timeframe. |
Report Facts
Census: 21
BIMS score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Muhammad D. Wurtele | Executive Director | Signed the initial comments and corrected the deficiency. |
| Director of Nursing | Involved in investigation and correction of deficiency; name not fully provided. | |
| Staff A | Licensed Practical Nurse interviewed regarding medication administration and incident. | |
| Staff B | Therapist interviewed regarding therapy services and incident reporting. | |
| Staff C | Director of Nursing interviewed regarding investigation and staff education. | |
| Administrator | Interviewed about awareness and response to the incident. |
Inspection Report
Original Licensing
Deficiencies: 0
Jul 26, 2021
Visit Reason
An initial health survey was conducted from July 21 to July 26, 2021, to assess the facility's compliance with health regulations.
Findings
The facility was found to be in substantial compliance with all regulations surveyed during the initial health survey.
Loading inspection reports...
