Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridge Crest At Meadow Ridge during CMS and state inspections, most recent first.
Confidential Resident Medications Sent With Another Resident's Discharge Pack: A resident was discharged with medication blister packs labeled for two other residents, including Abiraterone for prostate cancer and Potassium Chloride ER, mixed in with the discharge meds. The resident discovered the error after discharge and notified the facility; an RN was unaware of the mix-up, and the DON could not explain how the other residents' meds were included.
A resident with post-op pain needs and an order for Oxycodone was discharged with paperwork listing the narcotic, but the medication was not sent home. The RN responsible for discharge education and med reconciliation failed to ensure the resident was told the narcotic had to be signed out and failed to provide the Oxycodone at discharge; the resident later called reporting severe pain, and the DON stated the family returned later to retrieve the medication.
A resident with multiple cardiac conditions and an active DNR order, including RN pronouncement authority, was last seen in a recliner and later found on the floor after walking unassisted to use a commode. A CNA discovered the resident on the floor and notified nursing staff; an RN assessed the resident, who was moaning with minimal verbal response, and prepared to call EMS for transfer. Shortly thereafter, an LPN found the resident unresponsive with no pulse or respirations, left the room to get a crash cart and notify the RN, leaving the pulseless, apneic resident alone with two CNAs, and then returned and provided rescue breaths for about two minutes despite the DNR. The RN pronounced death without EMS on scene, and EMS was not contacted until roughly 30–38 minutes after the resident was found on the floor, contrary to facility policy requiring a 911 call for unanticipated deaths when EMS or hospice had not assumed care.
The facility failed to develop comprehensive hospice care plans for two residents admitted to hospice services. One resident with dementia and Alzheimer's was not provided a care plan due to a lack of follow-up communication from social services. Another resident with Parkinson's, dementia, and anxiety also lacked a hospice care plan due to confusion over responsibility between the MDS Coordinator and the Director of Social Services. Facility policies require the interdisciplinary team to develop care plans, but these were not followed, leading to the deficiency.
A resident with a history of falls experienced a significant fall resulting in major injuries, but the facility failed to update the care plan as required by policy. The DNS acknowledged the oversight, which was due to the resident being out of the facility for an extended period. The care plan was eventually revised, but not in a timely manner.
A resident with pressure ulcers was not provided proper care due to the facility's failure to ensure the air mattress was set to alternating pressure mode as required. The resident's air mattress was consistently set to static mode, contrary to physician orders and best practices, leading to inadequate care for the resident's pressure injuries.
The facility failed to properly manage medication storage and security, with expired medical kits found in the medication room and an LPN leaving a medication cart unlocked and unattended. Staff interviews confirmed that all personnel were responsible for discarding expired items and securing medication carts, but these policies were not followed, leading to deficiencies.
The facility failed to maintain a comprehensive system for reconciling controlled substances, with the DNS admitting to irregular audits and incomplete reconciliation processes. Medications from other sources lacked proper documentation, and facility policies for inventory control were not followed, leading to a deficiency in narcotic management.
A resident with severe cognitive impairment and incontinence was found in bed with soaked linens after refusing incontinent care. Although the refusal was reported verbally by a nursing assistant to an RN, neither staff member documented the refusal in the medical record as required by facility policy, nor was the oncoming shift notified.
Confidential Resident Medications Sent With Another Resident's Discharge Pack
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when medication blister packs containing resident-identifying information for two residents were improperly included with another resident's discharge medications. Resident #2 had diagnoses including falls, diabetes mellitus, and prostate cancer, and had a physician order for Abiraterone 250 mg, four tablets daily. Resident #3 had diagnoses including congestive heart failure, diabetes mellitus, atrial fibrillation, and anemia, and had a physician order for Potassium Chloride Extended Release 10 mEq tablets daily. Resident #1 was discharged from the facility, and photographs of the medications sent home showed a blister pack labeled for Resident #2's Abiraterone and a blister pack labeled for Resident #3's Potassium Chloride included in the discharge medication bag. Resident #1 reported discovering the medications after discharge and notified the facility. RN #1 stated she was unaware the medications belonging to the other two residents had been included, and the DON stated the facility learned of the error after Resident #1's notification and could not explain how the medications were included with the discharge medications.
Discharge Medication Not Provided
Penalty
Summary
The facility failed to ensure that a resident was discharged with all prescribed narcotic medications as ordered. The resident was admitted with diagnoses including aftercare following joint replacement surgery and neuropathy, was identified in the care plan as at risk for pain, and had physician orders for Oxycodone 5 mg every 4 hours as needed for pain, with an additional order for 2 tablets every 4 hours as needed for severe pain. The 5-day MDS showed a BIMS score of 15/15, indicating the resident was cognitively intact, and the resident received opioids within the prior 7 days. The resident was discharged home with medications and belongings, and the discharge paperwork listed Oxycodone as a medication to be used after discharge. However, the nursing note documented that narcotics were not given at the time of discharge, and a late entry stated the resident later called the facility reporting severe pain and that the Oxycodone had not been received. During interview, the resident stated the pain medication was missing from the discharge medications and that the resident had not been told it needed to be signed out. The RN stated she was responsible for discharge education and medication reconciliation, but failed to properly educate the resident and failed to ensure the resident signed for and received the prescribed narcotic before discharge. The DON stated the resident abruptly self-discharged and that nursing staff failed to provide the prescribed narcotic medication at discharge; the resident's family later returned to retrieve the Oxycodone.
Failure to Honor DNR, Delay EMS Notification, and Leave Unlicensed Staff With Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards when responding to a resident’s significant change in condition and honoring an active DNR order. The resident had multiple serious cardiac diagnoses, including heart failure, hypertension, atrial fibrillation, an aneurysm of the heart, and rheumatic tricuspid insufficiency, and was care planned as DNR with an order allowing RN pronouncement of death. The resident, cognitively intact with a BIMS score of 15 and requiring maximal assistance for ADLs and transfers, preferred to sleep in a recliner due to shortness of breath from CHF. On the night of the incident, the resident was last seen at approximately 2:30 AM in the recliner with legs elevated and nonskid socks in place, and was later found on the floor after walking unassisted to use the commode. After the fall, a nursing assistant found the resident on the floor around 2:45–2:50 AM, asked if the resident was okay, received no response, and left to notify the nurse. RN #1 responded, found the resident on the floor with minimal verbal responses and moaning, and completed an assessment while NAs obtained vital signs and LPN #1 obtained oxygen. During RN #1’s preparation to call emergency services for hospital transfer, LPN #1 notified RN #1 that the resident had become unresponsive and was without a pulse. RN #1 then assessed the resident and identified fixed and dilated pupils, no response to noxious stimuli, absent pulse, and absent respirations for one minute, and pronounced death at 2:58 AM under the existing DNR and RN May Pronounce orders. At this time, EMS had not yet been contacted. Following the pronouncement, there were additional failures related to professional standards and the DNR order. LPN #1 reported that upon entering the room as RN #1 was leaving to call 911, he observed the resident unresponsive with no pulse or respirations, then left the room to obtain the crash cart and notify RN #1, leaving the pulseless, apneic resident alone with two unlicensed NAs. When LPN #1 returned, he initiated rescue breaths for approximately two minutes despite the resident’s active DNR order, which under state code prohibits breathing or ventilation by assistive or mechanical means, including mouth-to-mask or bag-valve mask. EMS was not contacted until approximately 3:09–3:23 AM, about 30–38 minutes after the resident was found on the floor and after the RN’s pronouncement of death, despite facility policy directing staff to call 911 in the event of an unanticipated death when EMS or hospice had not taken over procedures for determination of death. EMS and police arrived later, confirmed the resident was pulseless and apneic, observed head trauma and early rigor, and a paramedic ultimately recorded the time of death at 3:43 AM.
Failure to Implement Hospice Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the Resident Care Plan (RCP) was comprehensive to include hospice care for two residents. Resident #29, diagnosed with dementia and Alzheimer's disease, was admitted to hospice care on December 6, 2024. However, a care plan regarding hospice services was not developed. The MDS Coordinators, responsible for implementing the care plan, were not notified of the hospice admission due to a lack of follow-up communication from social services. Although an initial email was sent on December 4, 2024, indicating a hospice referral, no subsequent notification was sent when the resident was officially admitted to hospice. Resident #46, admitted with diagnoses including Parkinson's disease, dementia, and anxiety, was also not provided with a comprehensive care plan upon admission to hospice services on November 20, 2024. Despite being sent to the hospital for agitation and returning to the facility, the RCP did not reflect the resident's hospice status. Interviews with the MDS Coordinator and the Director of Social Services revealed confusion over responsibility for developing the hospice care plan, resulting in the omission. The facility's policies, dated March 2022, state that the interdisciplinary team is responsible for developing resident care plans, and the hospice program policy from July 2017 emphasizes the facility's responsibility to administer therapies outlined in the hospice plan of care. Despite these policies, the lack of communication and clarity in roles led to the failure to implement appropriate hospice care plans for both residents.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the Resident Care Plan for one of the sampled residents was reviewed and revised following a fall that resulted in a major injury. The resident, who was admitted with diagnoses including heart failure, hypotension, and a history of falls, was identified as a fall risk. Despite this, after a fall on January 31, 2025, which resulted in significant injuries including a left femur fracture, odontoid fracture, closed head injury, and a scalp laceration, the care plan was not updated to reflect the incident. The facility's policy requires that the care plan be updated after each fall, but this was not done in this case. The Director of Nursing Services (DNS) acknowledged that the care plan was not updated due to an oversight, as the resident was out of the building for an extended period. The care plan was eventually revised on March 19, 2025, but the update was not timely and did not adhere to the facility's policy. The failure to update the care plan after the fall was identified during an interview and review of the care plan with the DNS, who confirmed the oversight and the importance of updating the care plan to prevent further falls.
Improper Air Mattress Settings for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper settings and usage of an air mattress for a resident with pressure ulcers, leading to a deficiency in care. Resident #45, who was admitted with multiple health issues including sepsis, pressure injuries, and chronic kidney disease, was identified as having pressure ulcers on the coccyx and left buttock. The resident's care plan included the use of an alternating pressure air mattress to prevent further skin breakdown. However, the physician orders did not specify the correct settings for the air mattress, such as whether it should be on alternating or static mode. Observations and interviews revealed that the air mattress for Resident #45 was consistently set to static mode, contrary to the intended alternating pressure mode. This setting was not adjusted according to the resident's weight or preferences, as required by the physician's orders. Staff members, including the Assistant Director of Nursing Services and a Registered Nurse, confirmed that they did not adjust the static/alternate button on the mattress pump, as it was not part of the order. The Director of Nursing Services was unaware that the mattress was set to static mode, which is not recommended for long-term use as it can contribute to wound deterioration. The Direct Home Medical Provider of equipment confirmed that the static mode should only be used for short periods, such as during care or meals, and that prolonged use could lead to further skin breakdown. The facility's failure to properly set and monitor the air mattress settings, as well as the lack of clear physician orders, resulted in inadequate care for Resident #45, who was at high risk for skin breakdown due to limited mobility and existing pressure injuries.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and disposal practices, leading to deficiencies in medication management. During an observation in the Cedar East medication room, it was found that several medical kits, including central line dressing change kits and IV start kits, were expired. These items were not patient-specific, and some were for residents no longer at the facility. Interviews with staff, including an LPN and the RN nursing supervisor, revealed that all staff were responsible for discarding expired items, but the nursing supervisor was specifically tasked with rotating stock. Despite this, expired items remained in the medication room, indicating a lapse in adherence to the facility's policy. Additionally, a separate observation noted that an LPN left a medication cart unlocked with the keys in the lock mechanism while walking away to a resident's room, leaving the cart unattended and unsecured. This occurred at the nurses' station, where two residents and three staff members passed by the unsecured cart. Interviews with the LPN and the RN nursing supervisor confirmed that the facility policy required medication carts to be locked and keys to be taken when not in use. The DNS also emphasized that nurses should maintain possession of the keys and ensure carts are not left unattended and unsecured.
Deficiency in Controlled Substance Reconciliation
Penalty
Summary
The facility failed to establish a comprehensive system for the reconciliation and documentation of controlled substances, leading to a deficiency in narcotic management. The Director of Nursing Services (DNS) was responsible for narcotic monitoring, including reconciliation and facility audits, but admitted to not having a regular process for reconciliation. The last audit was conducted in May 2024, and it was limited to the Omnicell machine, excluding medication carts on the units and controlled medications in the emergency box. The DNS described a process where nurses signed for narcotics upon delivery and placed the Controlled Substance Disposition Record (CSDR) copies in the DNS inbox, but these records were not used for reconciliation. Additionally, delivery slips from the pharmacy were sometimes discarded without being reviewed or reconciled. The facility's policies for inventory control and routine reconciliation of controlled substances were not followed. The policies required regular checks and reconciliation of controlled substances by two licensed nurses or a licensed nurse and another authorized healthcare professional. However, the DNS indicated that medications obtained from other pharmacies or brought in as personal medications were kept on unit medication carts with a facility-created medication count sheet, lacking corresponding CSDR copies for accountability. The facility failed to provide documentation of narcotic audits or reconciliation when requested, highlighting a significant gap in their controlled substance management system.
Failure to Document Resident Refusal of Care
Penalty
Summary
A deficiency occurred when staff failed to ensure the medical record for a resident with severe cognitive impairment and a history of stroke was complete and accurate regarding a refusal of care. The resident, who was occasionally incontinent of bowel and bladder and required two staff for care, was found in bed with soaked linens and incontinent pads. Documentation and staff statements revealed that the resident had refused incontinent care, and this refusal was reported by a nursing assistant to a registered nurse. Despite the facility's policy requiring documentation of care refusals, including the reason and interventions taken, neither the nursing assistant nor the registered nurse documented the resident's refusal of care in the medical record. Additionally, the registered nurse did not notify the oncoming shift of the refusal. The Director of Nursing confirmed that the refusal was not documented and stated that it was expected to be recorded according to facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilton Meadows Health Care Center | 4.1 mi | ★★★★★ | 1 | 0 |
| Laurel Ridge Center For Health & Rehabilitation | 4.9 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Norwalk | 8.4 mi | ★★★★★ | 25 | 0 |
| Saint John Paul Ii Center | 8.5 mi | ★★★★★ | 9 | 0 |
| Notre Dame Health And Rehabilitation Center | 9 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.