Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Cedar Ridge Center during CMS and state inspections, most recent first.
Unsafe and Unsanitary Ice Machine Areas: Multiple unit kitchenette and dining/common areas were observed with ice machine-related environmental concerns, including an improper air gap, warped and damaged cabinet surfaces with dark substance on exposed wood, a drain tube with a large black buildup, and a cabinet storing urinals, an incontinence brief, gloves, and loose garbage bags. Another kitchenette area was heavily soiled with dark unknown substances, and the counter behind the ice machine had exposed cut edges and discoloration from spilled coffee.
Physician block orders were not signed during required provider visits for 5 of 5 reviewed residents. Although provider progress notes were completed for each resident, there was no evidence the MD signed the orders on the visit dates, and the Market Clinical Advisor confirmed the findings during surveyor interview.
Improper Air Gap Installation and Unsanitary Food Preparation: The kitchenette ice machine had no visible air gap and was found to have less than the required 1-inch separation beneath the sink. In a separate event, an FSD and Dietary Aide handled canned peaches unsafely during dessert prep, including opening a dirty can, using a can wiped with sanitizer without rinsing, and repeatedly handling open fruit with a gloved hand before filling dessert dishes.
Infection Control Failure During Pressure Ulcer Dressing Change: An RN performed a wound dressing change for a resident with a Stage 3 heel pressure ulcer while using poor infection control practices. The RN contaminated a clean work field by handling the treatment cart, keys, and wound camera with the same gloves, then continued the procedure with soiled gloves while applying the dressing. The RN also did not follow the EBP sign outside the room by not wearing a protective gown during the wound care.
A resident filed multiple grievances about food quality, late meds, missed snacks, and missing hand wipes, but management did not consistently speak with the resident directly about the outcomes. The grievance file showed corrective actions were documented, yet there was no documentation that the resident was contacted for most of the concerns, and the resident reported not being told the results of the grievances.
A resident had a PRN lorazepam order for anxiety written for 6 months, but the clinical record did not contain a practitioner rationale for extending the psychotropic PRN order beyond 14 days. During interview, the DON confirmed the record lacked documentation supporting the extended duration.
A resident was diagnosed with bipolar disorder, but the clinical record did not show that the State mental health authority was notified for a new PASRR determination. The resident’s prior PASRR did not require a level II review, and an LSW confirmed that a new PASRR was not submitted after the diagnosis.
Failure to follow physician medication orders for blood pressure monitoring and administration. One resident received scheduled Carvedilol without documented SBP/DBP checks despite hold parameters, and another resident had Metoprolol doses held without documentation of the reason or evidence that the provider was contacted.
Multiple residents experienced significant delays in receiving assistance with ADLs, including toileting and changing, due to insufficient nursing staff. Residents reported waiting over an hour for call bells to be answered, resulting in soiling themselves and remaining in soiled conditions. Staff confirmed frequent short staffing, with some shifts covered by only one CNA and a nurse, leading to incomplete care and missed tasks such as baths and repositioning. Staffing schedules showed that minimum staffing requirements were not met for the majority of days reviewed.
A resident who transitioned from Medicare to private pay was not provided with consistent discharge planning or assistance with alternative placement, despite being assessed as appropriate for a lower level of care. The facility did not document an active discharge plan for several months, failed to communicate effectively with the POA, and staff threatened to contact APS when the POA attempted to arrange a transfer. Leadership acknowledged a lack of proactive discharge planning and indicated the resident would remain until funds were depleted, without evidence of equal access to services regardless of payor source.
The facility failed to develop and implement care plans for PTSD for three residents diagnosed with the condition. A resident admitted with PTSD lacked a documented care plan with goals, interventions, and triggers. Similarly, two other residents with PTSD diagnoses did not have care plans addressing their condition. The Market Clinical Advisor confirmed the absence of necessary components in the care plans for these residents.
The facility failed to maintain respiratory equipment in a sanitary manner, with observations of oxygen machines, nasal cannulas, and tubing improperly stored on the floor, on a wheelchair, and on a light fixture. An LPN and RN confirmed these items should be bagged and stored properly when not in use. Additionally, a resident was found sleeping on top of an unbagged nasal cannula, which should have been stored in a plastic bag.
The facility failed to maintain accurate records for controlled drugs and did not ensure proper documentation of shift counts across four units. Additionally, a resident requiring IV antibiotics did not receive the medication for three days due to supply issues, and the facility lacked an effective emergency pharmacy plan.
The facility failed to maintain a clean and sanitary kitchen, with food crumbs and debris found on various surfaces, and improperly stored food items in the refrigerator, freezer, and dry storage room. Additionally, the emergency food supply was stored alongside unsecured chemicals, posing a contamination risk. These issues were observed and reviewed with facility staff.
The facility failed to clearly communicate the terms of binding arbitration agreements to residents or their representatives. Several residents, including those who were cognitively intact, were unaware they had signed such agreements and did not receive education on their implications. The Admissions Director confirmed that arbitration agreements were embedded in admission documents and not thoroughly explained, with signatures applied automatically. Additionally, not all residents' records were checked for advanced directives before signing.
The facility failed to implement Enhanced Barrier Precautions for two residents with multi-drug resistant organisms, as required by their care plans. Signage indicating the need for precautions was missing, and staff were unaware of the necessary PPE. The Director of Nursing confirmed the signs had been removed, and the Senior Administrator cited guidance allowing discretion in precautions, leading to a deficiency in infection control practices.
The facility failed to provide sufficient staffing, particularly on weekends, leading to delayed assistance for residents with ADLs. A resident experienced incontinence after waiting 30 minutes for help, while another with PTSD was left in distress in the bathroom. A family member found a resident unattended with the call light on, and another resident was left wet all night due to a leaking catheter. These incidents highlight the facility's inability to meet residents' needs due to inadequate staffing.
The facility failed to maintain resident dignity by not serving all residents at the same table simultaneously during meal service. Observations and staff interviews revealed that meals were organized by room number, leading to staggered service times at tables. Despite resident concerns and discussions about changing the meal delivery order, no changes had been implemented.
A facility failed to update a care plan for a resident diagnosed with PTSD. Despite the diagnosis being made, the care plan lacked goals, interventions, or triggers for PTSD. This oversight was confirmed by the Market Clinical Advisor during an interview.
A facility failed to monitor a resident for behaviors and side effects of psychotropic medications, despite having active orders for anxiety and depression treatment. The resident's clinical record lacked documentation of necessary monitoring, which was confirmed by the Market Clinical Advisor during a review.
The facility did not properly label and dispose of insulin pens in the Scotch Pine House unit. An RN found an Aspart Insulin Flex Pen with an incorrect date and an undated Insulin Glargine-yfgn Solution Pen, both of which should have been discarded after 28 days according to manufacturer instructions.
A facility failed to notify a resident and their representative before changing the resident's room. A complaint was received, and during an interview, the resident and their family member confirmed they were not informed prior to the move. The clinical record lacked evidence of notification, and this was confirmed by the Market Clinical Advisor.
The facility failed to provide 8 residents with written information about their rights to accept or refuse treatment and to formulate an advance directive, as required by policy. The deficiency was confirmed by the Market Clinical Advisor, who noted the absence of documentation in the residents' medical records.
A facility failed to implement a baseline care plan within 48 hours for a resident admitted with a Deep Tissue Injury. The care plan lacked necessary goals and interventions for wound management, as required by facility policy. This deficiency was confirmed by the interim DON during a review.
A facility failed to maintain complete and accurate clinical records for a resident with a Deep Tissue Injury on the coccyx. The resident's Wound Evaluations indicated treatments that lacked corresponding provider orders, contrary to facility policy. Interviews with staff confirmed the absence of required orders, highlighting a deficiency in record-keeping and adherence to wound management protocols.
A resident received excessive doses of Ativan within 7 hours, contrary to the expected practice of administering it every 8 hours. The facility failed to document behavioral symptoms or non-pharmacological interventions before administering the medication and did not monitor for adverse effects. The resident's representative noted the resident appeared sedated and incoherent.
A resident experienced an unwitnessed fall, and the facility failed to notify the physician and the resident's representative immediately, as required by their Falls Management Policy. The fall was reported to the nurse late, and the representative only learned of the incident the next day from a CNA. The resident was in pain and was later found to have a fractured leg after being transported to the hospital.
A facility failed to implement a baseline care plan within 48 hours for a resident with multiple health conditions, including cardiovascular accident, hemiparesis, and neurogenic bladder. The care plan addressing immediate needs such as anticoagulant and antianxiety medication use, as well as other health concerns, was delayed by eight days. This deficiency was confirmed by the interim DON.
A resident experienced a fall due to the facility's failure to follow the care plan requiring a two-person assist transfer. A CNA attempted the transfer alone, resulting in the resident losing balance and falling. Additionally, the care plan inaccurately reflected the resident's advanced directive as Full Code, despite hospital records indicating a DNR status. The interim DON confirmed these deficiencies.
A facility failed to update a resident's care plan to reflect their current COVID-19 status and necessary precautions. Although the resident's medical record and room signage indicated confirmed infection and required PPE, the care plan was not revised accordingly. The DON confirmed this oversight during an interview.
The facility failed to provide a sanitary environment for respiratory care for two residents. A resident's nebulizer equipment was improperly stored and unlabeled, with no record of recent maintenance. Another resident's oxygen tubing was overdue for replacement, and the concentrator filter was dusty, contrary to facility policy. These issues were confirmed by staff.
A facility failed to accurately document the maintenance of oxygen equipment for a resident. Observations revealed outdated oxygen tubing and a dusty concentrator filter, despite records indicating recent maintenance. A nurse confirmed the tubing should be changed weekly, highlighting a discrepancy in documentation.
A facility failed to adhere to infection control protocols when two CNAs entered a resident's room under contact and airborne precautions without wearing the required PPE. Despite clear signage and available PPE, the CNAs mistakenly believed the resident was off precautions. This oversight was confirmed by an RN and discussed with the DON and Administrator.
A resident's bed rail was found broken and stuck in the up position, with the issue reported multiple times to nursing staff without resolution. Maintenance staff confirmed the malfunction but had no work order to address it. The deficiency was discussed with the Administrator.
A resident's dignity was compromised when their uncovered urine-filled Foley catheter bag was visible to passersby in the hallway and dining area. The resident expressed embarrassment and a desire for the bag to be covered. A surveyor observed this on one day, and a nurse confirmed the visibility of the bag.
A facility failed to assess and document a resident's ability to self-administer medication, as required by policy. The resident, with mild to moderately impaired cognition, was observed with eczema cream on their bedside table, despite an active order stating they may not self-administer medications. Interviews with staff confirmed the resident was given cream for self-administration without the necessary order, leading to a deficiency finding.
The facility failed to update and implement care plans for three residents, leading to deficiencies in monitoring their medical needs. A resident on Venlafaxine lacked side effect monitoring, another on Tacrolimus had no care plan goals for the medication, and a third with multiple diagnoses had no interventions for Furosemide use. These issues were confirmed by staff and discussed with the DON.
A facility failed to review and revise a care plan by the interdisciplinary team (IDT) for a resident after each assessment. The facility's policy requires a comprehensive care plan to be developed and reviewed by the IDT, including the resident and/or their representative, after each MDS assessment. However, the clinical record showed no care plan meeting was held following a quarterly MDS assessment, with the last documented IDT meeting occurring months earlier. This was confirmed by a Social Worker during an interview.
A facility failed to monitor and document behaviors for a resident on antipsychotic and antianxiety medications. The facility's policy requires behavior monitoring, but records lacked evidence of such monitoring. The DON stated that CNAs document behaviors and inform the charge nurse, but there was no regular documentation in the MAR/TAR, relying instead on staff trust.
Unsafe and Unsanitary Ice Machine Areas
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment in multiple kitchenette and dining/common areas where ice machines were observed. In the Blue Spruce unit kitchenette, the ice machine’s air gap was not visible at first, and when the Maintenance Director removed the screws from the cabinet doors, the air gap was found to be improper. Inside the cabinet, the bottom was warped, the edges of the wood panel were exposed, the back left corner was caved in, and there was a dark substance on the exposed panel edges. In the [NAME] unit dining/common area, the ice machine’s drain tube had a large buildup of a black substance hanging off the end, and the cabinet beneath it contained 2 urinals, 1 incontinence brief, an opened box of gloves, and several loose garbage bags. In the Scotch Pine unit kitchenette, the area around the ice machine was heavily soiled with dark unknown substances, which a staff member said was from a coffee pot overflow the prior week; the counter behind the ice machine had been cut to allow piping, leaving exposed cut edges and discoloration from spilled coffee.
Physician Block Orders Not Signed During Required Visits
Penalty
Summary
The facility failed to ensure that the resident's doctor reviewed the resident's total program of care and signed, dated, and completed physician block orders during required regulatory visits for 5 of 5 residents reviewed for unnecessary medications: R7, R59, R5, R14, and R33. Record reviews showed that each resident had a required regulatory visit completed, and each had a provider progress note completed on the same date as the visit, but there was no evidence that the physician block order was signed on the day of the visit. For R7, the required regulatory visit was documented on 2/24/26, but the physician block order was not signed. For R59, the visit was documented on 2/26/26, but the physician block order was not signed. For R5 and R14, the required regulatory visits were documented on 3/3/26, but the physician block orders were not signed. For R33, the required regulatory visit was documented on 3/17/26, but the physician block order was not signed. On 4/16/26 at 11:31 a.m., the Market Clinical Advisor confirmed the findings during interview with surveyors.
Improper Air Gap Installation and Unsanitary Food Preparation
Penalty
Summary
The facility failed to ensure that plumbing fixtures were properly installed to prevent backflow in the Blue Spruce unit kitchenette. During an observation tour, the kitchenette ice machine had no visible air gap at the counter level. When the Maintenance Director opened the secured cupboard doors beneath the sink, the air gap to the ice machine was observed to be less than the 1 inch required. The surveyor and Maintenance Director confirmed this direct connection of wastewater and potable water during the observation. The facility also failed to prepare food under sanitary conditions when the Food Service Director was observed preparing lunch desserts. He brought a can of peaches from the supply room that had a dirty, dusty top and opened it, contaminating the peaches with the soiled lid. A second can was wiped with a sanitizing cloth without rinsing the top, leaving sanitizing agent on the lid, and the can was then brought to the can opener. A Dietary Aide later handled the opened peaches with a gloved hand, cut pieces in her hand with a knife, and repeatedly reached back into the open can to fill dessert dishes before the surveyor intervened. The finding was confirmed by the surveyor, the Dietary Aide, and the Corporate Dietary Supervisor.
Infection Control Failure During Pressure Ulcer Dressing Change
Penalty
Summary
The facility failed to maintain an infection control program related to pressure ulcer treatment for one resident with a Stage 3 pressure ulcer on the left heel. The resident’s physician orders directed staff to cleanse the wound with wound cleanser, apply a medihoney dressing to the wound bed, and cover it with a foam border once daily and as needed. During observation of a pressure ulcer dressing change, the RN initially donned clean gloves and set up a clean work field at the foot of the bed, but then placed the wound cleanser bottle on soiled linen and the medihoney dressing and foam cover on the clean work field. The RN returned to the treatment cart with the same gloves, touched the cart, took keys from the cart and placed them in her pocket, and picked up a wound camera without cleaning it before bringing it to the bedside and placing it on the clean work field. With the same gloves, the RN removed the soiled dressing, changed gloves and cleansed the wound, then handled the camera again while repositioning the resident’s leg to take a picture. The RN then applied the medihoney dressing and foam while wearing gloves that were now soiled. In interview, the RN was also discussed for not following the Enhanced Barrier Precaution sign outside the resident’s room by not wearing a protective gown during the wound dressing change.
Failure to Notify Resident of Grievance Outcomes
Penalty
Summary
The facility failed to implement parts of its Grievance/Concern policy and procedure for one resident who filed multiple grievances. During an interview, the resident stated they had submitted several grievances over the past couple of months and had not been spoken to by management about the outcomes. The resident also stated that resident council meetings were used to discuss one grievance about snacks, but no one met with the resident in person to discuss it. Review of the grievance binder showed four grievances filed by the resident concerning hard scalloped potatoes, a late evening medication pass, not receiving afternoon snacks, and no Purell hand wipes being provided before meals. The documentation showed corrective actions were noted on the grievance forms, but for all but the medication-pass grievance there was no documentation that the resident was directly spoken to about the concerns. Review of the resident's clinical record also showed no evidence that the resident had been directly spoken to regarding the grievances. The facility policy required the department manager to contact the person filing the grievance to acknowledge receipt and notify the person of resolution in a timely manner. The Administrator stated he remembered discussing some grievance resolutions with the resident but was unsure which ones other than the late medication pass grievance.
Extended PRN Psychotropic Order Without Documented Rationale
Penalty
Summary
The facility failed to ensure that an as-needed psychotropic medication was ordered for 14 days or less unless there was a practitioner rationale for use beyond 14 days for one resident reviewed for unnecessary medications. Resident #59 had a physician order for lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety, with an order duration of 6 months from 11/24/25 to 5/24/26. Review of the resident’s clinical record found no evidence of a practitioner rationale supporting the extended PRN psychotropic order beyond 14 days. During an interview on 4/16/26 at 11:28 a.m., the DON confirmed that the record lacked documentation of a practitioner rationale for the 6-month PRN lorazepam order and stated she could not find one either.
Failure to Refer Resident for New PASRR Determination After Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that the State mental health authority was notified for Pre-admission Screening and Resident Review (PASRR) after a resident was newly diagnosed with bipolar disorder and/or experienced symptoms related to a mental disorder or trauma event. The resident’s PASRR, completed on 12/24/25, did not require a level II determination because the clinical record did not show a serious mental illness at that time. However, on 9/2/25, the resident was diagnosed with bipolar disorder, and the clinical record lacked evidence that the resident was referred to the State mental health authority for a new PASRR determination. During interview on 4/14/26, the Licensed Social Worker stated that a new PASRR was not submitted for the resident after the bipolar disorder diagnosis.
Failure to Follow Medication Orders for Blood Pressure Monitoring and Held Doses
Penalty
Summary
The facility failed to follow physician orders for blood pressure monitoring before administering Carvedilol for one resident with hypertension. The resident had an order for Carvedilol 3.125 mg by mouth every morning and at bedtime, with instructions to take with food and to hold the medication if systolic blood pressure was below 100 or diastolic blood pressure was below 60. Review of the EMAR showed no evidence that the resident’s systolic or diastolic blood pressure was monitored before scheduled Carvedilol doses during March 2026 and April 2026, and review of the PCC record showed no evidence that blood pressure was taken twice daily. The facility also failed to follow a physician order for another resident when Metoprolol Succinate ER 50 mg, ordered as 2 tablets by mouth one time a day for hypertension, was held on two occasions. The EMAR documented the doses as held on 4/10/26 and 4/13/26, but there was no evidence in the clinical record explaining why the medication was held or that the provider was contacted regarding the missed doses. During interview, the DON confirmed that the Metoprolol was not given as ordered on those dates.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, staffing schedule reviews, and direct observations. Residents reported excessive wait times for assistance with activities of daily living (ADLs), including toileting, changing, and ambulation. Several residents described waiting over an hour for call bells to be answered, resulting in soiling themselves and remaining in soiled conditions for extended periods. Staff confirmed that they were frequently short-staffed, with some shifts having only one CNA and a nurse covering the entire unit, leading to delays and incomplete care such as missed baths and repositioning. Staffing schedules reviewed showed that minimum staffing requirements were not met for 23 out of 31 days reviewed. Specific incidents included a resident being left on a bedpan for several hours overnight, ultimately having to remove it themselves, which resulted in a spill that was discovered by the nurse. Other residents reported being told by staff to limit their use of call bells due to short staffing, and some residents experienced a decline in mobility because staff were unable to assist with walking. Staff interviews corroborated these accounts, stating that care was not being provided in a timely manner and that residents were sometimes left in soiled beds. The deficiency was discussed with the Director of Nursing and the Administrator.
Failure to Ensure Equal Access and Discharge Planning Regardless of Payment Source
Penalty
Summary
The facility failed to ensure equal access to services and assistance with alternative placement for a resident whose payor source changed from Medicare Part A to private pay. The resident was admitted for skilled nursing services and, after Medicare coverage ended, continued to reside at the facility as a private pay resident. Assessments indicated that the resident no longer met the medical eligibility for nursing home level of care and was appropriate for a lower level of care, such as assisted living. Despite this, there was no active discharge plan documented in the clinical record for several months, and the facility did not provide evidence of consistent discharge planning or assistance with alternative placement. Documentation showed that the resident and their POA were informed about the need to move to a lower level of care, and a bed was available at an assisted living facility, but the resident refused to move. The resident's cognitive status declined over time, as indicated by BIMS scores, but the facility continued to allow the resident to remain without a documented discharge plan. The POA reported that the facility staff threatened to contact Adult Protective Services (APS) if attempts were made to move the resident, and staff confirmed that APS was contacted due to concerns about the resident's mental health and threats of self-harm during discussions about transfer. Interviews with facility leadership revealed a lack of communication with the POA regarding discharge planning and an absence of proactive steps to prepare for the resident's discharge, despite the resident being assessed as appropriate for a lower level of care months earlier. The facility indicated that if the resident's funds were depleted, they would be considered "days awaiting placement" pending Mainecare, and would need to accept an available assisted living facility within a certain distance. However, there was no evidence that the facility had actively assisted with alternative placement or ensured equal access to services regardless of payment source.
Failure to Develop PTSD Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans addressing Post-Traumatic Stress Disorder (PTSD) for three residents diagnosed with PTSD. Resident #1, admitted with a diagnosis of PTSD, lacked a documented care plan that included goals, interventions, and triggers related to PTSD. Similarly, Resident #5, also diagnosed with PTSD, did not have a care plan addressing their condition. Resident #51's medical record indicated a diagnosis of PTSD, yet there was no evidence of a care plan for PTSD. During an interview, the Market Clinical Advisor confirmed that the current care plans for these residents did not include necessary components to address PTSD.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner, as observed over three days of the survey. On the Blue Spruce Unit, a portable oxygen machine, nasal cannula, and tubing were found on the floor next to the exit door, which was confirmed by both an LPN and an RN as inappropriate storage. Additionally, oxygen tubing and a nasal cannula were observed hanging on a wheelchair handle instead of being stored in a bag, as confirmed by the same LPN and RN. These items had not been used by a resident for 2 to 3 days, yet were not stored properly. Further observations revealed that Resident #474's nasal cannula tubing was draped over a light fixture above the bed, with the prongs in direct contact with the fixture. In another instance, Resident #31's nasal cannula was found unbagged at the head of the bed, with the oxygen concentrator's storage bag empty and dated from a previous day. During a follow-up, the nasal cannula was found tucked between the resident's sheets, and the resident was observed sleeping on top of it. An RN confirmed that nasal cannulas should be stored in a plastic bag when not in use, and that tubing and bags are changed weekly.
Deficiencies in Controlled Substance Documentation and IV Antibiotic Availability
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs and did not ensure that two authorized individuals signed the Shift Count page at the change of each shift. This deficiency was observed across four units: Hickory, Elm, Blue Spruce, and Scotch Pine. The review of the Controlled Substance Books and Shift Counts revealed multiple instances where the required signatures were missing, indicating that the controlled substances count was not properly documented on several dates. This lack of documentation was confirmed during an interview with the Director of Nursing. Additionally, the facility failed to provide adequate pharmaceutical services to meet the needs of a resident requiring intravenous antibiotics. The resident, who was admitted with acute osteomyelitis and other serious conditions, did not receive the prescribed IV antibiotic Aztreonam for three days due to the pharmacy's supply issues. The facility's Market Clinical Advisor was unaware of local pharmacies that could handle emergency orders, and the contracted emergency pharmacy did not provide IV medications. This resulted in the resident missing seven doses of the prescribed medication.
Facility Fails to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. Various issues were noted, including food crumbs and debris on surfaces such as the metal storage cart, double-door oven, stovetop burner plates, and metal food prep table. Additionally, the air conditioner unit and oscillating fans were covered in dust and debris, and the floors throughout the kitchen were littered with food crumbs and debris. The reach-in refrigerator contained unlabeled and undated sliced fruit, and the walk-in refrigerator had several items, including a container of beef-flavored base and a metal bowl of iceberg lettuce, that were either undated, unlabeled, or uncovered. The walk-in freezer and dry storage room also contained improperly stored food items, such as an open bag of potato wedges and a plastic bag of flour-like substance, both unlabeled and undated. Furthermore, the facility's emergency food supply was improperly stored in the Central Supply Room, alongside unsecured chemicals such as Ecolab Grease Strip Plus and Oasis Multi-Quat Sanitizer. This storage arrangement posed a risk of contamination, as the emergency food supply was placed on open shelving next to and directly across from shelves containing these chemicals. These findings were reviewed with the facility's Dietary Aide, Food Services Account Manager, Dietary District Manager, Administrator, and interim Director of Nursing Services.
Failure to Communicate Arbitration Agreement Terms
Penalty
Summary
The facility failed to ensure that the terms and conditions of a binding arbitration agreement were clearly communicated to residents or their representatives. This deficiency was identified for four out of five residents reviewed for arbitration agreements. During interviews, residents and their representatives expressed that they were unaware of signing arbitration agreements and did not receive any education on what these agreements entailed. For instance, Resident #35, who was cognitively intact, stated that their child signed the admission paperwork, and they were not informed about the arbitration agreement. Similarly, Resident #46 and Resident #57, both cognitively intact, were unaware of having signed such agreements and expressed that they would not have signed if they understood the implications. In the case of Resident #331, who had moderate cognitive impairment, the spouse believed they had signed the admission paperwork but did not recall any explanation of arbitration agreements. The resident's medical record indicated a BIMS score of 8, suggesting moderate cognitive impairment, yet the arbitration agreement was embedded within the admission document and signed by the resident. The spouse confirmed that Resident #331 was not cognitively intact at the time of signing and could not comprehend the agreement. The facility's Admissions Director confirmed that arbitration agreements were included within the admission agreements, which were completed on a tablet. However, the Director admitted to not explaining the arbitration agreements thoroughly, including the residents' right to revoke the agreement within 30 days. The process involved sending the admission agreement via email, where the signature was automatically applied throughout the document. The Director also acknowledged that not all residents' records were checked for advanced directives before signing, indicating a lack of due diligence in ensuring residents or their representatives understood the agreements they were entering into.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of proper signage and staff awareness regarding Enhanced Barrier Precautions for two residents on the Elm House unit. Resident #327, who was admitted with a colonization of Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CRE), did not have the required signage indicating the need for Enhanced Barrier Precautions. A Registered Nurse initially stated that no special precautions were necessary, and a Certified Nursing Assistant (CNA) was unaware of the need for specific personal protective equipment (PPE) when caring for the resident. Similarly, Resident #331, who required Enhanced Barrier Precautions due to colonization with Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE), and Extended Spectrum Beta-Lactamase (ESBL), also lacked appropriate signage. Interviews with the resident's spouse and two CNAs revealed that staff were not informed about the necessary precautions. The clinical records for both residents clearly indicated the need for Enhanced Barrier Precautions, which were not being followed as per the facility's policy. The facility's policy, revised in December 2024, required Enhanced Barrier Precautions for residents with multi-drug resistant organisms, yet these were not implemented effectively. The Director of Nursing acknowledged that the signs had been removed after being posted, and the Senior Administrator mentioned guidance from the Maine CDC allowing discretion in the use of Enhanced Barrier Precautions. However, the lack of consistent implementation and staff awareness led to the deficiency in infection control practices.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was confirmed by the facility's Administrator during an interview with a surveyor, where it was acknowledged that the facility did not have enough staff to meet resident needs on weekends. The Payroll Based Journal staffing report indicated low weekend staffing during the fourth quarter of 2024. This staffing shortage affected residents' ability to receive timely assistance with Activities of Daily Living (ADLs). Multiple residents and a family member reported incidents of delayed response to call bells and inadequate assistance. One resident had to wait 30 minutes after using the call bell, resulting in incontinence due to the lack of staff. Another resident, who requires a sit-to-stand lift for transfers, experienced extended wait times due to insufficient staff available to assist. A family member reported that a resident was left unattended with the call light on, and another resident with PTSD expressed distress over being left in the bathroom for 20 minutes. Additionally, a resident was left wet all night due to a leaking catheter, as no staff responded to the call bell. These incidents highlight the facility's failure to provide adequate staffing to meet the residents' needs effectively.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service by not serving all residents seated at the same table simultaneously. During a dining observation, it was noted that residents at a table were served at different times, with one resident receiving their meal significantly later than others at the same table. This practice was inconsistent with the facility's stated procedure of serving complete tables before moving on to other tables or room service. The issue was highlighted in Resident Council Meeting Minutes, where concerns were raised about the order of meal service. Staff interviews confirmed that meals are typically organized by room number, which affects the order of service in the dining room. Despite discussions about changing the meal delivery order to align with dining room seating, no changes had been implemented. The Director of Nursing acknowledged the issue had been brought to the Quality Assurance and Performance Improvement meeting, but no performance improvement process was in place at the time of the surveyor's exit.
Failure to Update Care Plan for PTSD
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident was admitted to the facility on December 23, 2021, and was diagnosed with PTSD on April 14, 2023. However, the clinical record review revealed that the care plan did not include goals, interventions, or triggers related to PTSD. This deficiency was confirmed during an interview with the Market Clinical Advisor, who acknowledged that the care plan had not been updated to address the resident's PTSD needs.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to demonstrate evidence of behavior monitoring and monitoring for side effects of psychotropic medications for a resident diagnosed with anxiety and depression. The facility's policy on medication management requires evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, including adverse consequences of medications. However, the clinical record of the resident lacked evidence of a provider order or monitoring for behaviors and side effects related to the use of psychotropic medications. The resident was admitted with diagnoses of anxiety and depression and had active physician orders for several psychotropic medications, including Clonazepam, Mirtazapine, Escitalopram Oxalate, and Hydroxyzine HCl. Despite these orders, there was no documentation of behavior monitoring or monitoring for side effects in the resident's clinical record. This deficiency was confirmed during an interview with the Market Clinical Advisor, who reviewed the resident's entire clinical record and acknowledged the lack of necessary monitoring documentation.
Improper Labeling and Disposal of Insulin Pens
Penalty
Summary
The facility failed to comply with proper labeling and disposal protocols for biologicals in the Scotch Pine House unit. During an observation of the treatment cart with a Registered Nurse (RN), it was found that an opened Aspart Insulin Flex Pen was dated incorrectly, and an opened Insulin Glargine-yfgn Solution Pen was undated. Both insulin pens had manufacturer instructions indicating they should be discarded after 28 days of first use. The RN confirmed that the insulin pens were either expired or undated, indicating a lapse in adherence to manufacturer specifications for medication storage and disposal.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to appropriately notify a resident and their representative in a timely manner before changing the resident's room. A complaint was received by the Division of Licensing and Certification regarding a room change that occurred without proper notification. During an interview, a resident and their family member confirmed that they had not received any notification prior to the room change. A review of the resident's clinical record showed that the resident was moved from the Elm Unit to the Hickory Unit, but there was no evidence of any notification about the room change. This information was confirmed during an interview with the Market Clinical Advisor.
Failure to Provide Information on Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for 8 out of 16 residents reviewed for advanced directives. The facility's policy on Health Care Decision Making, revised on 1/8/24, mandates that residents be informed and provided with written information about their rights concerning medical treatment and advance directives. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the electronic medical records of the affected residents. The deficiency was confirmed during an interview with the Market Clinical Advisor, who acknowledged that the residents' medical records lacked evidence of advance directives or documentation that the residents or their representatives had been offered assistance to formulate an advance directive. This oversight affected residents who were admitted on various dates, and there was no evidence that the facility approached these residents or their representatives to discuss or provide information about advance directives, as required by the facility's policy.
Failure to Implement Baseline Care Plan for Resident with Deep Tissue Injury
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a Deep Tissue Injury. According to the facility's policy, a baseline person-centered care plan must be created within 48 hours of admission, including necessary healthcare information such as initial goals, physician orders, and interventions. However, upon review, it was found that the care plan for the resident, who was admitted with a Deep Tissue Injury on the coccyx, did not include goals and interventions for wound management. This deficiency was confirmed by the interim Director of Nursing during a review of the resident's care plan.
Incomplete Clinical Records for Wound Treatment
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident with a wound. The resident was admitted with a diagnosis of Deep Tissue Injury on the coccyx. Upon review of the resident's Wound Evaluation dated 12/11/24, it was noted that the wound was present on admission, and the treatment included cleansing with soap and water, with no dressing applied. A subsequent Wound Evaluation on 12/18/24 indicated that the wound was deteriorating, and the treatment included a generic wound cleanser and a primary dressing of zinc oxide covered with optifoam. However, the clinical record for the resident lacked evidence of a provider order for the treatments indicated in the Wound Evaluations dated 12/11/24 and 12/18/24. Interviews with the RN and PA-C revealed that it was expected for a provider order to match the treatments listed in the resident's Wound Evaluation assessment. The interim DON confirmed that the resident's clinical record did not contain a provider order for the treatments documented, indicating a failure to adhere to the facility's policy on Skin Integrity and Wound Management.
Excessive Ativan Administration and Lack of Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering excessive doses of Ativan within a short period and not monitoring for psychotropic medication side effects. A resident, who was admitted with a history of cardiovascular accident, depression, and anxiety, was prescribed Ativan to be taken three times daily as needed. However, the resident received 3 mg of Ativan within 7 hours, with doses administered at 8:00 p.m., 10:27 p.m., and 3:00 a.m. the following day. The medical record lacked evidence of behavioral symptoms justifying the PRN doses and did not document any non-pharmacological interventions attempted before administering the medication. Additionally, there was no documentation of monitoring for potential adverse consequences of Ativan use. The resident's representative expressed concerns about the resident's condition, noting that the resident appeared sedated and incoherent. The facility's Interim Director of Nursing and the PharMerica pharmacist both indicated that the expectation for administering medication three times daily is every 8 hours, which was not followed in this case.
Failure to Notify Physician and Representative After Resident Fall
Penalty
Summary
The facility failed to adhere to its Falls Management Policy and Procedure by not notifying a resident's physician and representative immediately after an unwitnessed fall. The policy requires that the physician and the resident's representative be informed of any fall, along with the physical findings and extent of injuries. In this case, a resident experienced a fall out of bed, which was not reported to the physician or the resident's representative until the following day. The resident's representative discovered the fall from a Certified Nurses Aide (CNA) and requested immediate hospital transport, where it was confirmed that the resident had a fractured leg. The Director of Nursing (DON) confirmed that the fall occurred in the late afternoon or early evening, but the CNA did not inform the nurse until later that night. Consequently, the physician and the resident's Power of Attorney (POA) were not notified until the next day. The resident was in visible pain, and upon hospital evaluation, a fracture was diagnosed. The medical record lacked evidence of timely notification to the physician and the resident's representative, highlighting a breach in the facility's protocol for managing falls.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident diagnosed with a cardiovascular accident with left side hemiparesis, requiring anticoagulant treatment, dysarthria with modified diet texture, thrombocytopenia, depression, anxiety with ordered antianxiety medications, and neurogenic bladder with an indwelling supra-pubic catheter. Upon review of the resident's clinical record, it was found that there was no evidence of a baseline care plan addressing the immediate health and safety needs related to the use of anticoagulant and antianxiety medications. Additionally, care plans for activities of daily living, impaired swallowing, cognitive loss, chronic pain, indwelling supra-pubic catheter, and risk of falls were not initiated until eight days after admission. This deficiency was confirmed during an interview with the interim Director of Nursing.
Failure to Follow Care Plan and Inaccurate Advanced Directive
Penalty
Summary
The facility failed to ensure that a care plan was followed for a resident requiring a two-person assist transfer, resulting in a fall. The incident occurred when a CNA attempted to transfer the resident to a commode with only one staff member assisting, contrary to the care plan's requirement for two-person assistance. During the transfer, the resident lost balance and fell, despite the CNA's attempt to catch them. This incident was confirmed by the interim Director of Nursing, who acknowledged that the care plan was not adhered to, leading to the resident's fall. Additionally, the facility did not maintain an accurate care plan regarding the resident's advanced directive code status. The resident's medical records from the hospital indicated a Do Not Resuscitate (DNR) status, which was also reflected in the hospital discharge summary and treatment directives. However, the care plan initiated by the facility inaccurately listed the resident's code status as Full Code. This discrepancy was confirmed by the interim Director of Nursing, highlighting a failure to ensure the care plan accurately reflected the resident's advanced directives.
Failure to Update Care Plan for COVID-19 Precautions
Penalty
Summary
The facility failed to revise the care plan to reflect a resident's current status concerning infection prevention and control. Specifically, the care plan for a resident diagnosed with COVID-19 was not updated to include the necessary precautions and status changes. The resident's electronic medical record indicated a confirmed COVID-19 infection with specific isolation precautions and personal protective equipment (PPE) requirements, including gloves, gown, N95 respirator, and eye protection. Despite these requirements being observed on signage and a PPE cart outside the resident's room, the care plan lacked evidence of being updated to reflect these changes. The Director of Nursing confirmed the care plan's deficiency in an interview.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, specifically concerning the use of nebulizers and oxygen equipment for two residents. For Resident #4, the nebulizer tubing and mouthpiece were found unlabeled and stored improperly on a bedside table without a treatment bag. The resident's medical record did not document a recent nebulizer treatment or any provider's order to change the nebulizer tubing, indicating a lack of adherence to the facility's policy requiring daily replacement and proper storage of nebulizer equipment. For Resident #6, the oxygen nasal cannula tubing was observed with a date indicating it had not been changed since 8/25/24, and the oxygen concentrator filter was coated with a thick layer of dust. This was confirmed by both a surveyor and an RN, who acknowledged that the tubing should have been changed weekly, and the filter cleaned regularly. The Director of Nursing confirmed these observations, highlighting a failure to follow the facility's procedures for maintaining respiratory equipment.
Inaccurate Documentation of Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to accurately document the Treatment Administration Record (TAR) for a resident using oxygen. On two separate occasions, a surveyor observed the resident using oxygen via nasal cannula with tubing dated from a previous week and a concentrator filter coated with dust. Despite nursing documentation indicating that the oxygen tubing was changed and the filter cleaned on a more recent date, the observations contradicted this record. A registered nurse confirmed that the tubing should be changed weekly, specifically on Sunday nights. This discrepancy was discussed with the Director of Nursing.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident observed during a survey. On the morning of September 3, 2024, two surveyors noted that a resident was under contact and airborne precautions, requiring the use of an N95 mask, gown, face shield, and gloves when entering the room. Despite clear signage and the availability of personal protective equipment (PPE) on a cart outside the resident's door, two Certified Nursing Assistants (CNAs) entered the room without donning the required PPE. Upon exiting, the CNAs admitted to not using the necessary protective gear, mistakenly believing the resident was no longer under precautions. The Registered Nurse confirmed the oversight, stating that the resident was to remain on precautions until September 4, 2024. This incident was discussed with the Director of Nursing and the Administrator later that day.
Failure to Maintain Resident's Bed in Safe Condition
Penalty
Summary
The facility failed to maintain a resident's bed in good repair and safe operating condition, as evidenced by a broken bed rail that was stuck in the up position. This issue was observed during a survey, where the resident's representative demonstrated the malfunctioning right side rail, which could not be lowered. The representative reported having informed the nursing staff multiple times over the past few weeks, but no action had been taken to address the issue. The left side rail was functioning properly, indicating the problem was isolated to the right side. Further interviews revealed that a CNA/Medication Tech was aware of the issue when the resident returned from a hospital evaluation following a fall. The ambulance crew and the CNA were unable to operate the right side rail. Maintenance personnel attempted to fix the rail but were unsuccessful and confirmed they had no work order for the repair. The deficiency was discussed with the facility's Administrator, highlighting a lack of communication and follow-up on maintenance requests.
Resident Dignity Compromised by Visible Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by allowing an uncovered urine-filled Foley catheter bag to be visible to passersby. On May 7, 2024, at 9:20 a.m., a surveyor observed the catheter bag hanging on the side of the bed, visible from the hallway and dining room. The resident expressed a desire for the bag to be covered, indicating embarrassment if it were seen by others. At 9:30 a.m., a Registered Nurse confirmed the visibility of the catheter bag to those passing by in the hallway and dining area. The issue was discussed with the Administrator on May 8, 2024, at 8:15 a.m.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to complete a Self-Administration of Medication Assessment for a resident reviewed for medication administration. The facility's policy requires an evaluation for safe and clinically appropriate capability for self-administration of medications, along with a physician or advanced practice provider order and care planning for self-administration and medication self-storage. However, the resident in question, who has mild to moderately impaired cognition, was observed with a plastic jar of A&D ointment on their bedside table, which they indicated was their eczema cream. The resident's care plan lacked evidence of their ability to self-administer medications, and their electronic medical record had an active order stating that the resident may not administer their own medications. During interviews, a CNA indicated that the resident self-administers their eczema cream, and an RN confirmed that the resident was given Triamcinolone Acetonide External Cream for self-administration without an order for self-administration in the clinical record. This discrepancy between the facility's policy and the actual practice observed by surveyors led to the identification of a deficiency in the facility's medication administration process.
Deficiencies in Care Plan Implementation and Monitoring
Penalty
Summary
The facility failed to update and implement comprehensive care plans for three residents, leading to deficiencies in monitoring and addressing their medical needs. Resident #1, who was prescribed Venlafaxine for depression, had no evidence of side effect monitoring in their clinical record, despite the care plan indicating a need for such monitoring. This oversight was confirmed by two registered nurses during a survey. Resident #4, who had a recent liver transplant and was on Tacrolimus to prevent organ rejection, lacked goals and interventions related to this medication in their care plan, which was initiated in 2021. Resident #6, with multiple diagnoses including congestive heart failure, dementia, and anxiety, had a care plan that did not include goals and interventions for the use of Furosemide, a diuretic prescribed for heart failure. Additionally, there was no evidence of monitoring for behaviors and side effects related to their psychiatric conditions and medications. These deficiencies were confirmed by a registered nurse and discussed with the Director of Nursing during the survey.
Failure to Revise Care Plan by IDT
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) for one of the sampled residents, Resident #6, after each assessment. According to the facility's policy on Person-Centered Care Plan, a comprehensive, individualized care plan should be developed and reviewed by the IDT, including the resident and/or their representative, after each Minimum Data Set (MDS) assessment. However, the clinical record for Resident #6 showed that a care plan meeting was not held following the quarterly MDS assessment dated January 23, 2024. The last documented IDT meeting for this resident was on October 23, 2023. This deficiency was confirmed during an interview with the Social Worker, who acknowledged that an IDT meeting should have been conducted within seven days of the MDS assessment.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor and document targeted behaviors to support the use of antipsychotic and antianxiety medications for a resident. The facility's policy on psychotropic medication use requires staff to monitor and document the resident's behavior using a behavioral monitoring chart or assessment record. However, a review of the resident's care plan and clinical records revealed a lack of evidence that the resident was being monitored for behaviors or side effects associated with the medications prescribed for anxiety and delusions. During an interview, the Director of Nursing (DON) indicated that behavior monitoring was documented by exception, with Certified Nursing Assistants (CNAs) responsible for documenting behaviors and informing the charge nurse, who should then include it in a progress note. The DON admitted that there was no regular documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) by nurses, relying instead on trust in the staff. This lack of documentation raises concerns about how the effectiveness of the medications is assessed and whether a Gradual Dose Reduction is justified.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 134 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Skowhegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlawn Rehabilitation & Nursing Center | 1.8 mi | ★★★★★ | 6 | 0 |
| Maplecrest Rehab & Living Center | 8.5 mi | ★★★★★ | 0 | 0 |
| Sanfield Rehab & Living Center | 14.2 mi | ★★★★★ | 0 | 0 |
| Waterville Center For Health And Rehab | 15.3 mi | ★★★★★ | 22 | 0 |
| Oak Grove Center | 16.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cedar Ridge Center.
100% money-back within 48 hours.
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.