SISSONVILLE, WV - Federal health inspectors cited Cedar Ridge Center for immediate jeopardy violations after discovering the facility failed to maintain life-saving emergency equipment and allowed water temperatures to reach dangerous levels during an April inspection.
Emergency Respiratory Equipment Missing When Needed Most
The most serious violation involved a resident with a tracheostomy who lacked the required emergency replacement equipment at their bedside. When inspectors asked staff to locate the spare tracheostomy tube that physician orders mandated be kept in the room, it took more than 15 minutes to find the supplies in a storage closet.
The resident had a 7.5 size tracheostomy tube in place, but facility records incorrectly indicated it was a 6.5 size. The respiratory therapist acknowledged ordering the wrong size initially, stating he made an error when reviewing the hospital transfer information. The proper emergency supplies - both the current size and one size smaller - were not available at the bedside as required by physician orders and the facility's care plan.
"A deep cough, moving around, just about anything could make it pop out," the respiratory therapist explained about circumstances that could dislodge a tracheostomy tube.
When a tracheostomy becomes dislodged, medical protocols require immediate replacement to maintain the patient's airway. Delays in reestablishing the airway can cause severe oxygen deprivation, brain injury, cardiac arrest, and potentially death. Medical literature confirms that timely intervention is critical, with delayed recognition or failure to reestablish the airway within minutes potentially causing irreversible harm.
The facility's own procedures required licensed staff to verify the correct tube size and ensure two replacement tubes - current size and one size smaller - remain available at bedside along with manual resuscitation equipment. The inspection revealed these protocols were not followed.
Dangerously Hot Water Creates Burn Risk
Inspectors also discovered water temperatures reaching dangerous levels in the facility's dining room sink. The maintenance director confirmed the hot water tank serving the dining room was connected to the kitchen system, which requires higher temperatures for food safety. This resulted in water temperatures exceeding safe limits for resident use.
Federal regulations require nursing home water temperatures not exceed 110 degrees Fahrenheit to prevent burns and scalding injuries. Water temperatures above this threshold can cause severe burns within seconds of contact, particularly dangerous for elderly residents who may have decreased sensation, slower reaction times, or mobility limitations.
The facility immediately shut off water to the dining room sink and posted out-of-service signage upon discovery. Maintenance staff conducted a comprehensive audit of water temperatures throughout the facility to identify any additional safety hazards.
Pain Management Failures Documented
Inspectors observed a hospice resident experiencing prolonged pain without adequate assessment or intervention. During one evening observation period, the resident was heard calling out and requesting help for approximately 50 minutes before staff responded. When a nurse finally entered the room, the resident indicated he was in pain and needed medication.
"Please help me," the resident was heard calling from his room before staff intervention.
The resident's care plan specified multiple pain management interventions, including observing for pain indicators, providing non-pharmacological approaches, and administering medications as ordered. However, medication records showed the resident had gone over 24 hours without receiving prescribed morphine, and no non-pharmacological interventions were documented throughout the month.
Additionally, medication administration records revealed discrepancies in pain medication dosing, with narcotic logs showing smaller amounts signed out than what progress notes indicated was administered to residents.
Systemic Medication Administration Problems
The inspection uncovered widespread issues with medication timing and administration for dialysis patients. Five residents receiving dialysis were not getting their phosphate-binding medications with meals as prescribed. These medications must be taken with food to effectively control phosphorus levels in the blood.
Phosphate binders like Renvela, Velphoro, calcium acetate, and Auryxia work by binding to phosphorus in food to prevent absorption. When taken outside of meal times, these medications lose their effectiveness, potentially leading to dangerous phosphorus buildup in dialysis patients.
Medication administration records showed these drugs were being given during routine medication passes rather than with meals, reducing their therapeutic benefit. For residents leaving early for dialysis appointments, medications were sometimes administered after they had already departed for treatment.
Staffing Shortages Impact Care Quality
Multiple residents and family members reported significant delays in receiving assistance, with call lights going unanswered for extended periods. During the inspection, one resident waited over 40 minutes for help with personal care needs.
"When they let you lay in your own crap for over 40 minutes, it's really hard to be sympathetic," stated one cognitively intact resident about wait times for assistance.
Residents reported typical wait times of 1-2 hours for call light responses, with some delays extending up to 3 hours. Weekend shifts were identified as particularly problematic for staffing levels and response times.
Staff members confirmed ongoing challenges with adequate coverage, citing frequent call-offs and difficulty retaining employees. Nurse aides reported feeling overwhelmed by resident-to-staff ratios, particularly during evening and night shifts.
Infection Control and Documentation Issues
Additional violations included infection control lapses in shower areas, where unlabeled personal care products created cross-contamination risks between residents. The facility also failed to maintain accurate medication records for controlled substances and did not properly respond to consulting pharmacist recommendations for medication safety monitoring.
Record-keeping problems extended to care plan updates, with facility staff continuing to monitor dialysis access sites that were no longer functional and tracking medical equipment that had been discontinued.
Federal Response and Corrective Measures
The State Agency determined the respiratory care violations posed immediate jeopardy to resident health and safety. The facility was notified of the immediate jeopardy status and required to submit an immediate plan of correction. After implementation of emergency measures, the immediate jeopardy determination was removed later that evening.
The facility's correction plan included placing emergency respiratory equipment at the affected resident's bedside, providing staff re-education on tracheostomy care protocols, and implementing daily monitoring procedures to ensure compliance with respiratory care requirements.
For water temperature issues, the facility committed to comprehensive temperature monitoring across all resident areas, maintenance staff retraining, and establishing regular oversight through quality improvement committees.
The inspection highlights the critical importance of maintaining emergency medical equipment and ensuring basic safety measures in nursing home environments. For residents with complex medical needs like tracheostomies and dialysis, proper equipment placement and medication timing can be matters of life and death.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Ridge Center from 2025-04-16 including all violations, facility responses, and corrective action plans.
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