Cedar Ridge Inn: Glaucoma Drops Stopped Without Order - NM
The resident, identified in inspection records only as Resident 2, has glaucoma, dementia, and a history of cerebral infarction — the death of brain tissue from loss of blood flow. She has lived at the facility since July 2023. Her doctor prescribed Dorzolamide HCI-Timolol Maleate eye drops, a combination medication used to reduce dangerous pressure inside the eye, to be given twice daily: once in the morning and once in the evening.
The drops were discontinued on March 5, 2026. No physician ordered it.
Federal inspectors arrived at Cedar Ridge Inn on April 28, 2026, following a complaint. What they found, documented across medication records, nursing notes, and staff interviews, was a straightforward error with a weeks-long shadow: a licensed practical nurse had accidentally discontinued the prescription, the mistake went undetected for five days, and by the time anyone caught it, the resident had gone without her glaucoma drops for an extended stretch that the facility's own records do not fully account for.
The medication administration record for March 2026 is direct about what happened. Nurses did not give Resident 2 her Dorzolamide HCI-Timolol Maleate drops because, the record states, there was no active order available. The order had been discontinued. Nobody had authorized that.
Licensed Practical Nurse 1 told inspectors she was the one who accidentally discontinued the eye drops. She said she did not realize the mistake for five days. Once she did, she called the pharmacist, who sent new drops to the facility.
But the timeline in the physician order records tells a more complicated story than a single five-day gap.
The original orders, both the morning and evening doses, were entered on February 23, 2026, and discontinued on March 4, 2026. New orders for the same medication were entered on March 11 and March 12. Those orders were then discontinued again on April 8, 2026. The nursing progress note from April 28 states the drops were discontinued on March 5 by the facility, without a physician's order to do so.
What that sequence shows is a resident whose glaucoma medication was stopped, restarted, and stopped again across a span of roughly six weeks, with at least one of those discontinuations confirmed to have occurred without any physician authorization.
The facility's administrator did not dispute any of it. Speaking with inspectors at 12:50 in the afternoon on April 28, he confirmed that the eye drops were discontinued by accident. He said the resident's daughter had been informed and was upset. He said the medication should not have been discontinued without physician authorization.
The Director of Nursing said the same thing, in almost the same words, when inspectors spoke with her separately that afternoon.
What neither the administrator nor the Director of Nursing addressed, at least not in the portions of the inspection record made public, was the second discontinuation, the one on April 8, and whether that one also lacked a physician order. The inspection narrative centers on the March event. The April discontinuation appears in the order records without explanation.
Glaucoma is a condition that can cause permanent, irreversible vision loss. The drops Resident 2 was prescribed work by reducing intraocular pressure, the buildup of fluid inside the eye that, left uncontrolled, damages the optic nerve. Missing doses does not produce immediate, visible symptoms. The damage accumulates. A patient with dementia cannot reliably report changes in her vision, cannot tell a nurse that things look different, cannot advocate for the medication she is not receiving.
Resident 2's daughter could. And according to the facility's own administrator, she did, once she found out. She was upset.
The inspection was classified as a complaint survey, meaning someone contacted regulators before inspectors arrived. The records do not specify who filed the complaint or what it alleged. What the inspection found, at minimum, confirmed that a medication prescribed by a physician to manage a condition that causes blindness was stopped without that physician's knowledge or authorization, and that the patient went without it while the error sat undetected.
Cedar Ridge Inn sits at 800 Saguaro Trail in Farmington, a city of roughly 45,000 in the northwest corner of New Mexico. The facility is certified through Medicare and Medicaid under provider number 325113.
The deficiency was cited at a level of minimal harm or potential for actual harm. That classification reflects the regulatory judgment that no documented harm had yet occurred, not that none could. The inspection report itself notes the practice is likely to result in residents not maintaining their optimal health as planned by their medical provider, and potential complications.
For a resident with dementia and glaucoma, the gap between those two phrases, likely to result and potential complications, is the space where irreversible vision loss lives.
LPN 1's account to inspectors was candid. She made the error. She caught it five days later. She called the pharmacist. New drops arrived. What her account does not explain, and what the inspection record does not resolve, is why the physician orders show a pattern of starts and stops across February, March, and April, or who authorized, or failed to authorize, the April 8 discontinuation.
The administrator's framing, that this was an accident, that the daughter was told, that it should not have happened, is accurate as far as it goes. Accidents happen in nursing facilities. Medication errors are among the most common. What distinguishes a serious systemic failure from an isolated mistake is usually what happens next: whether the error is caught quickly, whether it is reported, whether the conditions that allowed it are examined and changed.
The inspection record does not say how long Resident 2 went without her drops in total, across all the gaps the order history suggests. It does not say whether her eye pressure was checked after the medication lapsed. It does not say whether her ophthalmologist was notified. It does not say what her daughter, who was upset, was told about what the missed medication might mean for her mother's eyes.
What it says is that a nurse accidentally stopped the drops, that nobody noticed for five days, and that a woman with dementia and glaucoma went without a medication her doctor ordered to protect what remains of her sight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Ridge Inn from 2026-04-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Cedar Ridge Inn in Farmington, NM was cited for violations during a health inspection on April 28, 2026.
She has lived at the facility since July 2023.
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.