Cedar Ridge Inn: Pressure Wound Neglect Causes Infection - NM
That was the day anyone at Cedar Ridge Inn called a physician.
The resident, identified in inspection records only as Resident 10, had a wound that staff first knew about on July 18, 2025. For more than two weeks after that, the wound care nurse responsible for monitoring it did not notify a doctor that it was deteriorating. She did not call the Director of Nursing either, even as the wound turned red and hot. Nobody escalated. Nobody called.
The Director of Nursing, who acknowledged she became aware of the wound on July 18, was out of the building from July 28 through August 1. The Assistant Director of Nursing was also gone during the same stretch. When the DON returned and was finally confronted with the photographs on August 5, she said the wound looked red and hot and she suspected infection. She called the physician that day and arranged for a Wound Care Nurse Practitioner consult.
Antibiotics were started on August 6. Five days later, Resident 10 was hospitalized with an infection.
The DON told inspectors she had not been aware the wound was deteriorating before August 5. She said the wound care nurse should have called the physician when the wound worsened, and should have notified her even while she was out. That acknowledgment, offered after the fact, described exactly what did not happen.
The Medical Director told inspectors on August 27 that he did not remember when he was notified about the wound. He said he was usually in the building every week. He said staff were expected to notify him of any change in condition, including worsening wounds. He confirmed he knew about the wound before the resident was sent to the hospital.
The Wound Care Nurse Practitioner saw the wound for the first time on August 7, two days after the DON finally made the call. By then, the wound was unstageable, covered with 100 percent dry eschar. She told inspectors she could not perform a wound culture because of the eschar. She said the Santyl that had already been ordered was the treatment she would have chosen. She did not see Resident 10 again. He was gone to the hospital before she returned.
The family member who had been watching this unfold since July 18 told inspectors she had talked to nursing staff repeatedly about the wound getting worse. She went to the DON herself on August 5 with the pictures. She described watching it deteriorate over those weeks, raising it with staff, and waiting.
CMS rated the violation at the level of actual harm.
What the inspection report describes is a gap of at least 18 days between when staff knew a wound existed and when a physician was called, during which the wound worsened to the point of suspected infection, and the only person who forced action was a family member with photographs on her phone.
Resident 10's wife had been watching his wound get worse since July 18. She talked to nurses. She waited. On August 5, she walked in with pictures and made it impossible to ignore. Six days later, her husband was in the hospital.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Ridge Inn from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
Cedar Ridge Inn in Farmington, NM was cited for neglect violations during a health inspection on August 27, 2025.
That was the day anyone at Cedar Ridge Inn called a physician.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.