Cedar Ridge Center

F-F689

The Maintenance Director (MD) turned the water off to the dining room sink on 4/16/25 immediately upon discovery. The Nursing Home Administrator (NHA) posted an out of service sign on the dining room sink on 4/16/25 at 2:45pm.

All the residents of the facility have the potential to be affected.

The Director of Maintenance/designee completed an audit on 4/16/25 of water temperatures from point of use on each resident room, resident care areas, and shower rooms to ensure water temperature is 110 degrees or below with any corrective action immediately upon discovery.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Re-education was provided by the Nursing Home Administrator (NHA) /Designee to all maintenance employees starting on 4/16/25 to ensure water temperatures from point of use in the facility is 110 degrees Level of Harm - Immediate or below. A Post-test to validate understanding. Any maintenance employees not available during this time jeopardy to resident health or frame will be provided re-education, including post-test and return demonstration by DON/designee upon the safety beginning of next shift to work. New maintenance employees will be provided education, including post-test

during orientation by the DON/designee. Residents Affected - Some

The Maintenance Director (MD) /Designee will monitor facility water temperatures from point of service on each hallway a random room, resident care areas, and shower rooms starting on 4/16/25 to ensure water temperatures are 110 degrees or below daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter.

Results of monitors will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.

An additional interview with the Maintenance Director at Approximately 6:00 PM confirmed the hot water tank which fed the hand sink in the main dining room was tied in with the tank that fed the kitchen. He stated, It would have been hotter because the kitchen water has to be hotter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50795

Residents Affected - Few Based on observation, interview, and record review, the facility failed to notify the physician of a newly admitted resident's indwelling catheter, and failed to obtain a physician's order for the care and maintenance of the catheter. In addition, the facility failed to provide the appropriate catheter care to prevent potential Catheter Associated Urinary Tract Infections (CAUTI's). This was true for one (1) of five (5) residents reviewed for catheter care. Resident Identifier: #266. Facility census: 111.

Findings Included:

a) Resident #266

During an interview on 04/13/25 at approximately 2:14 PM, Resident #266 stated she was looking forward to getting her catheter removed. Upon being asked if the facility provided catheter care, resident stated the staff usually emptied her catheter bag when it filled up.

A review of the Minimum Data Set (MDS) data presented to the surveyors upon entry indicated Resident #266 was admitted to the facility on [DATE REDACTED]. The MDS did not show Resident #266 had an indwelling urinary catheter.

A review of Resident #266's records, on 04/14/25 at 9:30 AM, revealed no orders pertaining to a catheter, or catheter related care.

On 04/14/25 at approximately 12:15 PM, Licensed Practical Nurse (LPN) #26 confirmed there were no orders entered, and in fact the MDS did not identify the resident had a catheter.

During an interview with the Unit Manager (UM) #97 on 04/14/25 at 12:25 PM, UM #97 confirmed there were no physicians' orders for catheter care. A request for the task sheets for catheter care revealed the resident was designated as Independent. No documentation was available confirming the facility had provided catheter care to the resident.

During an interview with the Director of Nursing (DON) on 04/14/25 at 1:00 PM, she confirmed no orders had been obtained from the physician for catheter care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31826 jeopardy to resident health or safety Based on observation, record review, and staff review, the facility failed to ensure Resident #111 received respiratory care to ensure Resident #111's airway remained intact and was able to be reestablished Residents Affected - Few immediately if the tracheotomy tube would become dislodged. This was true for one (1) resident reviewed for

the care area of Respiratory care during the long term care survey process.

The facility failed to ensure they had the supplies at bedside to replace Resident #111's tracheotomy canula.

The physician orders and Resident #111's care plan dictated the supplies were to be kept at bedside. When

the staff was asked were the supplies were to replace the canula were located, it took greater than 15 minutes to find the needed supplies in the supply closet. They were not kept at bedside as directed in the physician order and care plan.

The failure to replace Resident #111's tracheotomy cannula timely could result in the immediate loss of a secure airway leading to severe hypoxia, anoxic brain injury, cardiopulmonary arrest and potentially death. Medical literature affirms that timely intervention is critical. Delayed recognition or failure to reestablish the airway with in minutes can cause irreversible harm.

The State Agency (SA) determined this failure put Resident #111 in an Immediate Jeopardy (IJ) situation.

The facility was notified of the immediate jeopardy at 5:03 PM on 04/15/25. The facility submitted and the SA accepted a plan of correction (POC) at 5:20 PM. After observation of implementation of the POC the IJ was abated at 6:27 PM on 04/15/25.

After the IJ was abated and the immediacy was removed, but a deficient practice remained for Resident #97. Resident #97 was ordered to have continuous oxygen but it was not in place. After the abatement the scope and severity was decreased from a J to a D.

Resident Identifiers: #111 and #97. Facility Census: 111.

Findings Included:

a) Resident #111

Resident #111 was admitted to the facility on [DATE REDACTED]. The resident record contained the following physician orders related to trach care:

-- Type of Trach 6.5 size of trach 6 spare trach kept at bedside and ambu bag at bedside.

A review of the residents care plan found the following care plan interventions related to the trach included:

-- Keep a spare trach/orturator trach kit at bedside. Added to the care plan 03/24/25.

-- Type of trach: 6.5 size of trach 6 keep spare trach and ambu bag at beside. Added to the care plan on 03/24/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Observations of Resident #111 with the Director of Nursing (DON) at approximately 11:45 am found the resident did not have a size six (6) trach at her bed side. She was then asked if she could show the surveyor Level of Harm - Immediate that she had one in the facility. She summoned the Respiratory Therapist (RT) who looked in the supplies jeopardy to resident health or they were unable to locate a size 6. safety

The RT then went to Resident #111's room to see what size trach was currently in place. The RT determined Residents Affected - Few it was a size 7.5 instead of a 6.5. He was then able to locate the size 7 trach kit which would have been the size down. It took greater than 15 minutes to locate the trach kit which according to the physicians orders and care plan should have been located at bed side. He agreed it needed to be at bed side and not in the storage area.

An additional interview with the RT, on 04/15/25 at 1:25 PM, confirmed he was one who ordered the wrong size trach. He stated that when she arrived the hospital did not send orders with her regarding the size of her trach. He stated that he looked at it and they are new and have different numbers. He stated that he looked at the chart and made an error when putting in the orders and the care plan. When asked what type of circumstances would cause the trach to dislodge the RT stated, A deep cough moving around just about anything could make it pop out.

An interview with Licensed Practical Nurse #60 (LPN), confirmed if the trach would come out he would hold

the oxygen over the hole and call a Registered Nurse. He confirmed, he was not allowed to replace the trach.

A review of the facility's procedure related to Tracheotomy Tube Change/reinsertation,found primary licensed staff inserts the new tube. The DON indicated this meant an LPN can reinsert the new tube. She stated he knew that so I don't know why he told you that.

Further review of the procedure for Tracheotomy Tube Change/reinsertation found the following, .9. Verify size of trach that patient has in place to assure appropriate tube size and type. 10. Verify the two replacement trachs, current size and one size below, are available at bedside along with manual resuscitator .

An additional interview with the RT at, 04/15/25 at 2:26 PM, revealed he should have ordered a 6un75H in

the trach and she should have had a 5un70h at bedside. He stated that he went by the diameter of 7.5 instead of the size of the trach. However the ordered reflected a 6.5 not the diameter of 7.5. The RT confirmed the residents trach is uncuffed and they are more likely to dislodge.

A follow up interview with the DON after the facility's was notified of the IJ confirmed it took greater than 15 minutes to find the correct size trach. She stated, But we was not in an emergency situation. She felt they would have found it quicker had the trach been dislodged however the chaos of any emergency likely would cause further delay. She agreed the spare trach should have been at bedside.

b) Facility's Plan of Correction

The facility's plan of correction read as follows (typed as written):

The Director of Nursing (DON)/designee placed the emergency trach as ordered by the resident's 11 bedside on 4/15/25 @ 500pm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 All residents with tracheostomies of the facility have the potential to be affected.

Level of Harm - Immediate As of 4/15/25 no other residents with tracheostomies in the facility at this time. jeopardy to resident health or safety Re-education was provided by the Director of Nursing(DON)/Designee to all licensed nurses starting on 4/15/25 to ensure residents with a tracheostomy tube in place will have a spare tracheostomy tube with Residents Affected - Few obturator of the same manufacturer brand and size currently used AND one size smaller at the bedside. A Post-test to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee upon the beginning of next shift to work. New Licensed nurses will be provided education, including post-test during orientation by the DON/designee. Annual in-servicing will be provided to licensed nurses regarding the care of indwelling urinary catheters.

The Unit Managers (UM)/Designee will conduct observations starting on 4/15/25 to ensure residents with a tracheostomy tube in place will have a spare tracheostomy tube with obturator of the same manufacturer brand and size currently used and one size smaller at the bedside daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter.

Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.

c) Resident #97

The facility failed to provide oxygen via nasal cannula for Resident #97 who was ordered oxygen continuously. On 04/16/25 at 10:25 AM, the state surveyor observed Resident #97 not wearing his oxygen and the concentrator turned off. Resident #97's physician's order stated, Oxygen at 2 L/min via Nasal Cannula continuously. Licensed Practical Nurse (LPN) #60 confirmed the resident was not wearing his oxygen. LPN #60 placed the resident's nasal cannula, turned the oxygen concentrator on, and changed the

the liters to two (2) liters per minute from the setting of three (3) liters per minute. LPN #60 stated, It's supposed to be two (2) liters it was three (3) liters. The resident's oxygen saturation level was 96%.

51553

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Actual harm 31826

Residents Affected - Few Based on observation, record review and staff interview, the facility failed to ensure orders and interventions were followed to control pain for Residents #42 and #87. This was true for two (2) of six (6) residents reviewed for pain management during the survey process. Resident identifiers: #42, #87. Facility census: 111.

The State Agency (SA) determined physical harm was caused to Resident #42 when the facility failed to check on, and assess, Resident #42 for pain, for approximately 50 minutes, despite him yelling out the entire duration, until surveyor intervention. At which time, it was discovered by Licensed Practical Nurse (LPN) #36, Resident #42 was in pain and requested pain medication. Furthermore, physical harm was determined based upon the review of the Medication Administration Record (MAR), orders, and care plan, which revealed the resident had not gotten the correct dose of pain medication, had not received any nonpharmacological interventions for pain as ordered, and was not receiving interventions for pain management that were in place in his care plan.

Findings Include:

a) Resident #42

Resident #42 received hospice services due to an end stage diagnosis of History of CVA (cerebrovascular accident).

Resident #42 has an order for: Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 10 mg by mouth every two (2) hours as needed for pain/dyspnena. Give 0.50 ML. Hold for Sedation 0.50 ml, every two hours as needed for pain.

At approximately 11:30 AM on 4/13/25, during observations in the North hall of the facility, Resident #42 was observed to be yelling out. Review of the resident's record on 04/13/25, revealed indicators for pain were yelling out, restlessness, tenseness. Resident #42 was observed to be yelling out again at approximately 1:30 PM, 2:40 PM, and 3:08 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 At approximately 9:05 PM on 4/14/25, Resident #42 was heard yelling out in his room. His door was pulled around, almost shut completely, left barely cracked open. This surveyor stood in front of the resident's door Level of Harm - Actual harm until approximately 9:45 PM. No one entered the room to check on the resident during this time period. All three (3) Nurse Aides (NA), #13, #15, #21, assigned to that side of the facility, walked by and Licensed Residents Affected - Few Practical Nurse (LPN) #36 was on the medication cart in the hallway. At approximately 9:45 PM someone could be heard yelling from inside the room, Please help me. Still, no staff member entered the room to check on the resident. At approximately 9:50 PM, this surveyor told LPN #36 Someone in the room is yelling for help. The LPN stated, He's usually confused, but I'll check on him. Upon entering the room, Resident #42 was still yelling out. LPN #36 asked Resident #42 if he was in pain and he indicated he was. She asked him what he needed, and he held up his index finger and thumb, as if he was holding something between them.

The nurse asked Do you need your pain medication? Resident #42 indicated he did. LPN #36 administered

the pain medication at approximately 9:55 PM. Approximately 20 minutes later, the resident was found to be calmer and yelling out less. LPN #36 was asked what the resident's indicators of pain were. LPN #36 stated his indicators were yelling out, tenseness, and restlessness. LPN confirmed the resident exhibited all symptoms at this time. LPN was asked how the resident communicated pain, to which she stated he was nonverbal and the staff look for things such as yelling out, tenseness, restlessness. LPN #36 stated at this point, the resident should be assessed for pain.

Upon review of the resident's Medication Administration Record (MAR) for the month of April 25, on 04/15/25, it was noted zero (0) nonpharmacological interventions for pain management had been implemented, as the entire month, up to 04/15/25 was empty.

It was also noted, from the resident's MAR, he was administered morphine at 8:25 PM on 04/13/25 and did not receive it again until 9:52 PM on 4/14/25, going over 24 hours without receiving it.

Review of the narcotic sheet on 04/15/25, for the morphine, indicated on 04/9/25 at 8:45 PM, 0.25 ml of morphine was signed out on the log and administered to the resident. 0.25 was signed out and administered at 5:24 AM on 04/10/25. Resident #42 was given half of his ordered dose at this time, as he had an active order for 0.5 ml of Morphine at the time of administration. Progress notes for those days stated the resident was administered 0.5 ml on both occasions, despite the narcotic log stating 0.25 ml was signed out.

Upon review of the resident's care plan, the following interventions were noted regarding pain management:

Observe for pain. Attempt non-pharmacologic interventions to alleviate pain and

document effectiveness. Administer pain medication as ordered and document

effectiveness/side effects.

Observe for pain and administer as ordered per MD and position for comfort.

Resident and HCS will achieve the highest possible level of peace by the time of

death as evidenced by alleviated pain and resident exhibited calmness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Assess for pain, restlessness, agitation, constipation and other symptoms of discomfort. Medicate as ordered and evaluate effectiveness. Provide non-pharmacological approaches to aide in decreasing discomfort. Level of Harm - Actual harm Offer non-pharmacologic interventions prior to PRN pain medication administration. Residents Affected - Few Observe for non-verbal signs/symptoms of pain and medicate as ordered.

Observe for nonverbal signs of pain: increase in agitation, grimace, resistance to care.

During an interview with the Director of Nursing (DON) on 04/16/25 at approximately 4:00 PM, it was confirmed, based on observations and review of the narcotic log and MAR, Resident #42's care plan was not being implemented regarding his pain management. He had received the incorrect dose of morphine (0.25 ml instead of the prescribed 0.5 ml); He did not receive nonpharmacological interventions for pain management as ordered. The DON also confirmed LPN #36 expressed to her Resident #42 was in pain upon the DON's arrival to the facility at approximately 9:50 PM on 04/14/25, as the nurse told the DON she was preparing to administer the resident's morphine.

b) Resident #87

A review of Resident #87's medical record on the morning of 04/16/25 found the resident was ordered Hydrocodone 5-325 by mouth every 6 hours for pain,

The medication administration record for the month of 03/2025 and the month of 04/2025 along with the controlled substance log coinciding with these month was requested.

Upon review of the MAR and the controlled substance log it was found on 04/06/25 at 6:00 PM the medication was initialed as administered but was not signed out on the controlled substance log. This indicated the medication was not administered because it was not removed from the medication card. This same situation occurred again on 04/13/25 for the 6:00 am dose.

This was confirmed with Corporate Registered Nurse (CRN) #132 at 5:00 PM at on 04/16/25.

49467

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50795 potential for actual harm Based on observation, interview and record review, the facility failed to follow administration directions for Residents Affected - Some medications prescribed for the control of phosphorous levels for dialysis patients. This was true for 5 of 5 residents on dialysis. Resident Identifiers: Residents #33, #88, #94, #105 and #108. Facility census:111.

Findings Include:

a) Resident #33

Record review and interview on 04/13/25 at 2:35 PM revealed, Resident #33 is a [AGE] year-old female on hemodialysis diagnosed with the following conditions:

Chronic systolic heart failure

Chronic respiratory failure with hypoxia

Type 2 diabetes mellitus with polyneuropathy

End-stage renal disease on hemodialysis

Dilated cardiomyopathy

History of nicotine dependence

Hypertension

Morbid obesity

Gastroesophageal reflux disease

Anemia

A review of the resident's medication orders on 04/15/25 at approximately 11:55 AM revealed Resident #33 was prescribed:

Renvela Oral Tablet 800 MG (Sevelamer Carbonate). Give 3 tablets by mouth before meals for end stage renal disease

Renvela is a medication classified as a phosphate binder. It is designed to be taken three times a day with meals to help control phosphorus levels in the body. By binding to phosphorus in food, Renvela prevents it from being absorbed. Phosphate binders should generally be taken within 5 to 10 minutes before or immediately after meals and snacks. It is important not to take Renvela with other medications; instead, those should be administered at least 1 hour before or 3 hours after taking Renvela.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Record review on 04/15/25 at approximately 1:30 PM revealed the resident is scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. The orders state the following: Level of Harm - Minimal harm or potential for actual harm Pick-up time 5:30am

Residents Affected - Some Chair time 6:30 am

A review of the Medication Administration Record (MAR) for Resident #33 on 04/15/25 at 3:13 PM revealed

the administration time for Renvela, was after the resident had left the facility for dialysis on Tuesdays, Thursdays and Saturdays. In addition, Renvela was not administered at meal times as evidenced by the following entries in the MAR:

04/01/24 (Tuesday)

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/02/25

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/03/25 (Thursday)

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/04/25

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/05/25 (Saturday)

6:30 AM - Renvela 800 MG tablets X 3.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 11:30 AM - Renvela 800 MG tablets X 3

Level of Harm - Minimal harm or 4:30 PM - Renvela 800 MG tablets X 3 potential for actual harm 04/06/25 Residents Affected - Some 6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/07/25

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/08/25 (Tuesday)

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/09/25

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/10/25 (Thursday)

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/11/25

6:30 AM - Renvela 800 MG tablets X 3.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 11:30 AM - Renvela 800 MG tablets X 3

Level of Harm - Minimal harm or 4:30 PM - Renvela 800 MG tablets X 3 potential for actual harm 04/12/25 (Saturday) Residents Affected - Some 6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/13/25

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/14/25

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

04/15/25 (Tuesday)

6:30 AM - Renvela 800 MG tablets X 3.

11:30 AM - Renvela 800 MG tablets X 3

4:30 PM - Renvela 800 MG tablets X 3

During an interview with Unit Manager (UM) #97 on 04/15/25 at 3:25 PM, UM #97 stated the medication was being administered during med pass and not during meal times.

An interview with the Director of Nursing (DON) on 04/16/2 at approximately 3:35 PM, confirmed the medication was not being administered with food.

b) Resident #88

Record review and interview revealed Resident #88 is a [AGE] year-old female on hemodialysis. Resident was diagnosed with the following conditions:

Chronic Kidney Disease Stage 5

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Unspecified Hydronephrosis

Level of Harm - Minimal harm or Essential (Primary) Hypertension potential for actual harm Other Hyperlipidemia Residents Affected - Some Age-Related cognitive decline

Muscle weakness (Generalized)

Hypothyroidism (Unspecified)

Acquired absence of kidney

Hyperkalemia

A review of the resident's medication orders on 04/15/25 at approximately 10:55 AM revealed Resident #33 was prescribed:

Renvela Oral Tablet 800 MG (Sevelamer Carbonate). Give 2 tablet by mouth three times a day for CKD. To be taken with food/meals.

Renvela is a medication classified as a phosphate binder. It is designed to be taken three times a day with meals to help control phosphorus levels in the body. By binding to phosphorus in food, Renvela prevents it from being absorbed. Phosphate binders should generally be taken within 5 to 10 minutes before or immediately after meals and snacks. It is important not to take Renvela with other medications; instead, those should be administered at least 1 hour before or 3 hours after taking Renvela.

Record review on 04/15/25 at approximately 12:30 PM revealed the resident is scheduled for dialysis on Mondays, Wednesdays, and Fridays. The orders state the following:

Facility to transport

Chair time 11:00 am

Early lunch meal at 10:00 due to dialysis schedule

A review of the Medication Administration Record (MAR) for Resident #33 on 04/15/25 at 3:25 PM revealed

the administration time for Renvela, was scheduled to meet the resident's dialysis schedule on Monday's, Wednesday's, and Friday's, however, the medication administration schedule was not adjusted for non-dialysis days, resulting in the medication not being administered with meals as evidenced by the following entries in the MAR:

04/01/24

10:00 AM - Renvela 800 MG tablets X 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 1:00 PM - Renvela 800 MG tablets X 2

Level of Harm - Minimal harm or 5:00 PM - Renvela 800 MG tablets X 2 potential for actual harm 04/02/25 (Wednesday) Residents Affected - Some 10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/03/25

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/04/25 (Friday)

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/05/25

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/06/25

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/07/25 (Monday)

10:00 AM - Renvela 800 MG tablets X 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 1:00 PM - Renvela 800 MG tablets X 2

Level of Harm - Minimal harm or 5:00 PM - Renvela 800 MG tablets X 2 potential for actual harm 04/08/25 Residents Affected - Some 10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/09/25 (Wednesday)

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/10/25

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/11/25 (Friday)

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/12/25

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/13/25

10:00 AM - Renvela 800 MG tablets X 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 1:00 PM - Renvela 800 MG tablets X 2

Level of Harm - Minimal harm or 5:00 PM - Renvela 800 MG tablets X 2 potential for actual harm 04/14/25 (Monday) Residents Affected - Some 10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

04/15/25

10:00 AM - Renvela 800 MG tablets X 2.

1:00 PM - Renvela 800 MG tablets X 2

5:00 PM - Renvela 800 MG tablets X 2

On 04/15/25 at 10:58 AM, during medication administration, LPN #26 was observed administering the following medications to Resident #88:

Clopidogrel Bisulfate Tablet 75 MG 1 tablet

Ferrous Sulfate Oral Tablet 325 (65 Fe) MG 1 tablet

Renvela Oral Tablet 800 MG X 2 tablets

Sodium Bicarbonate Oral Tablet 650 MG 1 tablet

During an interview with UM #97 on 04/15/25 at 11:15 AM, UM #97 stated the medications were being administered during med pass and not during meal times.

An interview with the DON on 04/16/2 at approximately 3:35 PM, DON confirmed the medication was not being administered, as prescribed, with food.

c) Resident #94

Record review on 04/15/25 at approximately 11:50 AM revealed Resident #94 is a [AGE] year-old male Patient is long-term resident of the facility. Resident is diagnosed with the following:

End-stage renal disease on hemodialysis

Hepatitis B

Heart failure with midrange ejection fraction

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Anemia

Level of Harm - Minimal harm or Hypertension potential for actual harm Hypothyroidism Residents Affected - Some Cerebrovascular accident

Presence of AV shunt

Chronic back pain

Pancytopenia

Record review on 04/15/25 at approximately 1:20 PM revealed the resident is scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. The orders state the following:

Time for Pick up: 7am

Transport to [dialysis]

A review of the resident's medication orders on 04/15/25 at approximately 12:53 PM revealed Resident #94 was prescribed the following medication:

Velphoro Oral Tablet Chewable 500 MG (Sucroferric Oxyhydroxide - Give 2 tablets by mouth with meals for ESRD (Chew or Crush)

Velphoro (sucroferric oxyhydroxide) is a phosphate binder indicated for the control of serum phosphorus levels in patients with chronic kidney disease on dialysis. Velphoro is to be taken with food or meals. Tablets must be chewed or crushed; tablets must not be swallowed whole.

A review of the Medication Administration Record (MAR) for Resident #94 on 04/15/25 at approximately 2:13 PM revealed Velphorx was administered after the resident left the facility for dialysis at 7:00 AM on Tuesdays, Thursdays and Saturdays. Furthermore, Velphoro was not given at meal times, as evidenced by

the following entries in the MAR:

04/01/24 (Tuesday)

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/02/25

7:30 AM - Velphoro 500 MG tablets X 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 11:30 AM - Velphoro 500 MG tablets X 2

Level of Harm - Minimal harm or 4:30 PM - Velphoro 500 MG tablets X 2 potential for actual harm 04/03/25 (Thursday) Residents Affected - Some 7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/04/25

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/05/25 (Saturday)

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/06/25

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/07/25

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/08/25 (Tuesday)

7:30 AM - Velphoro 500 MG tablets X 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 11:30 AM - Velphoro 500 MG tablets X 2

Level of Harm - Minimal harm or 4:30 PM - Velphoro 500 MG tablets X 2 potential for actual harm 04/09/25 Residents Affected - Some 7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/10/25 (Thursday)

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/11/25

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/12/25 (Saturday)

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/13/25

7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

04/14/25

7:30 AM - Velphoro 500 MG tablets X 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 11:30 AM - Velphoro 500 MG tablets X 2

Level of Harm - Minimal harm or 4:30 PM - Velphoro 500 MG tablets X 2 potential for actual harm 04/15/25 (Tuesday) Residents Affected - Some 7:30 AM - Velphoro 500 MG tablets X 2

11:30 AM - Velphoro 500 MG tablets X 2

4:30 PM - Velphoro 500 MG tablets X 2

During an interview with UM #97 on 04/15/25 at 11:35 AM, UM #97 stated the medication was being administered during med pass and not during meal times.

An interview with the DON on 04/16/2 at approximately 3:35 PM, DON confirmed the medication was not being administered, as prescribed, with food.

d) Resident #105

A closed record review on 04/15/25 at approximately 4:15 PM revealed Resident #105 was a [AGE] year-old male who was on hemodialysis. Resident was diagnosed with the following diagnoses:

Anemia of chronic disease

CAD

Carotid stenosis

Cataracts bilateral

CHF

Type2 diabetes

Diarrhea

End-stage renal disease on dialysis

Hypertension

Hyperkalemia

Hyperlipidemia

Record review further revealed resident was scheduled for dialysis on Mondays, Wednesdays and Fridays. Dialysis orders specified the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Pick up 6:30 AM

Level of Harm - Minimal harm or Chair time of 7:00 AM potential for actual harm Early breakfast meal at 6:00 am due to dialysis schedule Monday-Wednesday-Friday Residents Affected - Some

A review of the resident's medication orders on 04/15/25 at approximately 4:53 PM revealed Resident #105 was prescribed:

Calcium Acetate Oral Tablet 667 MG (Calcium Acetate (Phosphate Binder)) Give 2 tablet by mouth with meals for Supplement

Calcium Acetate is a phosphate binder used to treat hyperphosphatemia in dialysis patients. It is recommended this medication be taken with meals. Other medications should not be taken with Calcium acetate. They should be taken at least one (1) hour before or three (3) hours after calcium acetate administration.

A closed record review of the Medication Administration Record (MAR) for Resident #105 on 04/15/25 at approximately 2:20 PM revealed the administration time for Calcium acetate was after the resident had left

the faciity on Mondays, Wednesdays and Fridays. In addition, Calcium acetate was not administered at meal times, as evidenced by the following entries in the MAR:

03/20/25

7:30 AM - Calcium acetate 667 MG tablets X 2.

11:30 AM - Calcium acetate 667 MG tablets X 2

4:30 PM - Calcium acetate 667 MG tablets X 2

03/21/25 (Friday)

7:30 AM - Calcium acetate 667 MG tablets X 2.

11:30 AM - Calcium acetate 667 MG tablets X 2

4:30 PM - Calcium acetate 667 MG tablets X 2

03/22/25

7:30 AM - Calcium acetate 667 MG tablets X 2.

11:30 AM - Calcium acetate 667 MG tablets X 2

4:30 PM - Calcium acetate 667 MG tablets X 2

03/23/25

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 7:30 AM - Calcium acetate 667 MG tablets X 2.

Level of Harm - Minimal harm or 11:30 AM - Calcium acetate 667 MG tablets X 2 potential for actual harm 4:30 PM - Calcium acetate 667 MG tablets X 2 Residents Affected - Some 03/24/25 (Monday)

7:30 AM - Calcium acetate 667 MG tablets X 2.

11:30 AM - Calcium acetate 667 MG tablets X 2

4:30 PM - Calcium acetate 667 MG tablets X 2

03/25/25

7:30 AM - Calcium acetate 667 MG tablets X 2.

11:30 AM - Calcium acetate 667 MG tablets X 2

4:30 PM - Calcium acetate 667 MG tablets X 2

03/26/25 (Wednesday)

7:30 AM - Calcium acetate 667 MG tablets X 2.

11:30 AM - Calcium acetate 667 MG tablets X 2

4:30 PM - Calcium acetate 667 MG tablets X 2

03/27/25

7:30 AM - Calcium acetate 667 MG tablets X 2.

11:30 AM - Calcium acetate 667 MG tablets X 2

4:30 PM - Calcium acetate 667 MG tablets X 2

During an interview with the DON on 04/16/2 at approximately 3:45 PM, DON confirmed the medication was not being administered, as prescribed, with food.

e) Resident #108

During an interview on 04/13/25 at 2:45 PM Resident #105 stated he did not get his phosphate binders with his meals. He stated the medication was dispensed during med pass, with the other medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Record review on 04/13/25 at approximately 3:20 PM revealed Resident #108 is a [AGE] year-old male with

a history of end-stage renal disease on dialysis, He is diagnosed with: Level of Harm - Minimal harm or potential for actual harm End-stage renal disease on hemodialysis

Residents Affected - Some Cerebrovascular accident

Heart failure

Hypertension

Hyperlipidemia

Depression

Chronic venous stasis

Cardiomyopathy

Record review further revealed resident was scheduled for dialysis on Mondays, Wednesdays and Fridays. Dialysis orders specified the following:

Time for Pickup 6:10 AM

Chair time 6:50 AM

Early breakfast meal at 545 AM due to dialysis schedule

A review of the resident's medication orders on 04/13/25 at approximately 3:53 PM revealed Resident #108 was prescribed:

Auryxia Oral Tablet 1 GM 210 MG (Fe) (Ferric citrate) - Give 1 tablets by mouth with meals for anemia

Auryxia (ferric citrate) is a medication used to manage two conditions: high phosphate levels in the blood (hyperphosphatemia) and iron deficiency anemia (IDA) in individuals with chronic kidney disease (CKD). It works as a phosphate binder, reducing the amount of phosphate absorbed from food, and as an iron supplement. Auryxia should be taken with meals.

A review of the Medication Administration Record (MAR) for Resident #108 on 04/13/25 at approximately 3:2 revealed the administration time for Auryxia was after the resident had left the facility for dialysis on Mondays, Wednesdays, and Fridays. In addition, Auryxia was not administered at meal times, as evidenced by the following entries in the MAR:

04/03/25

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

Level of Harm - Minimal harm or 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) potential for actual harm 04/04/25 (Friday) Residents Affected - Some 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/05/25

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/06/25

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/07/25 (Monday)

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/08/25

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/09/25 (Wednesday)

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

Level of Harm - Minimal harm or 5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate) potential for actual harm 04/10/25 Residents Affected - Some 7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/11/25 (Friday)

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/12/25

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

04/13/25 (Monday)

7:00 AM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

12:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

5:00 PM - Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate)

During an interview with UM #97 on 04/15/25 at 11:41 AM, UM #97 stated the medication was being administered during med pass and not during meal times.

An interview with the DON on 04/16/2 at approximately 3:35 PM, DON confirmed the medication was not being administered, as prescribed, with food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 49467

Residents Affected - Many Based on observations and resident and staff interviews, the facility failed to deploy sufficient direct care staff to meet the needs of the resident population of the facility. This had the potential to affect all residents residing in the facility. Resident identifiers: #94, #58, #51, #85, #91, and #84. Facility census: 111.

Findings include:

a) Resident #94

On 04/13/25 at approximately 3:09 PM, an interview was conducted with Resident #94. Resident #94 stated

the facility was very understaffed. Resident #94 said, They keep telling me they're hiring people, but no one ever stays. The ones that don't do their job, they keep because they can't keep other people, so they have no choice but to keep them.

At approximately 9:05 PM on 4/14/25, the call light for Resident #94's room was observed ringing in the North Hall of the facility.

At approximately 9:16 PM, Resident #94 was observed yelling Hello multiple times from inside his room, but did not receive an answer. During this time, Licensed Practical Nurse (LPN) #36 and Nurse Aide (NA) #21 were on the hallway.

LPN #36 was passing medications and NA #21 was observed going back and forth between other resident rooms. At approximately 9:20 PM, NA #21 went to a soiled linen bin outside of Resident #94's room, at which time he yelled, Can I get an aide please? NA #21 placed items into the soiled linen bin, walked down the hallway, and did not acknowledge the resident.

At approximately 9:23 PM NA #13 entered the Hallway next to Resident #94's room and answered another resident's call light. At approximately 9:25 PM, LPN #36 answered Resident #94's call light. Upon entering

the resident's room, she asked Resident #94 what he needed, to which he responded, I need changed.

LPN #36 stated, I'll find out who your aide is and let them know. LPN #36 proceeded to turn the resident's light off and go back to the medication cart. At approximately 9:33 PM LPN #36 stated to NA #13 (Resident #94's name) needs changed. NA #13 then stated, I'm on back hallway; I'm just covering this until (NA #15's name) gets back. NA #13 then proceeded to walk past Resident #94's room, did not address the resident, and did not enter the room. When Resident #94 saw the aide walk by, he yelled Did we find an aide yet? At approximately 9:36 PM LPN #36 told NA #15, (Resident #94's name) needs help. He needs changed. I told

the other aide earlier, but she didn't change him. NA #15 acknowledged Resident #94's needs and retrieved

a cart with meal trays on it and pushed it to the dining room. Upon returning to the hallway at approximately 9:45 PM, NA #15 entered Resident #94's room and provided care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Resident #94 has a Brief Interview for Mental Status (BIMS) Score of 15, indicating he is cognitively intact.

Level of Harm - Minimal harm or At approximately 10:00 PM, an interview was conducted with Resident #94 regarding his wait time for care. potential for actual harm Resident #94 was asked how long his light had been on. Resident #94 stated Since about nine (9) o ' clock, about 40 to 45 minutes. Resident #94 then stated I know they ' re understaffed around here and I try to be Residents Affected - Many sympathetic to them because of that. But when they let you lay in your own crap for over 40 minutes, it ' s really hard to be sympathetic.

b) Resident #58

At approximately 4:45 PM on 4/16/25, an interview was conducted with Resident #58. Resident #58 stated

We wait an hour and a half, sometimes two (2) hours for someone to answer our lights. Sometimes all we might need is water, but it takes them that long just to come see. If it was something simple, they could turn

the light off and fix it, but they won ' t. Night shift is the worst. I feel like the response time at night should be faster because people are sleeping. They want us to sleep but if we need changed and can ' t get them to change us, we can ' t sleep. Some of them have attitudes. Some of them are always saying they hate this place and hate it being so understaffed. Sometimes the staff here will voice to us that they are understaffed. That's their explanation as to why they are late. I get straight cathed and I always have to wait. I told a nurse at 3:00 PM that I needed one and I am still waiting. He said he would find a woman to come do it and I am still waiting. If you need food heated it and you ask them to do it, they will you they have to do something else first and then you have to wait a while for them to come back and heat your food up.

c) Resident #51

On 04/13/25 at approximately 12:28 PM, Resident #51 stated the following about the facility ' s staffing: Weekends are the worst as far as staffing and wait times. 40 minutes is usually the minimum. They'll come in and say Sorry, we are short, we will be back. They usually tell me what's going on out there.

d) Resident #85

At approximately 12:45 PM on 4/13/25, an interview was conducted with Resident #87. During the interview,

the resident was asked if he received assistance from the staff with Activities of Daily Living (ADLs), such as bathing. Resident #87 stated I ' m supposed to have them on Monday and Friday, but sometimes they just put them off. They are working short a lot of the time and they tell me they will get it done, but they never do. I usually have bed baths, which is fine, but I haven't had one in a while. I wouldn't mind a shower every now and then, either.

Upon review of the resident's bathing task history for the last 90 days, it was revealed he did not receive a bed bath or shower on the following days:

Friday 1/24/25

Friday 1/31/25

Monday 2/3/25

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Friday 2/14/25

Level of Harm - Minimal harm or Friday 2/21/25 potential for actual harm Friday 2/28/25 Residents Affected - Many Monday 3/3/25

Friday 3/28/25

Friday 4/11/25

During an interview with the Director of Nursing (DON) at approximately 4:00 PM on 4/16/25, she confirmed

the missing dates for the resident ' s bathing. The facility did not provide any additional documentation by the end of the survey process.

e) Resident #91

On 04/13/25 at approximately 02:36 PM, Resident stated the following about facility staffing in an interview: It takes them an hour to an hour and a half to answer your light when you need help.

f) Resident #84

At approximately 10:00 AM on 4/14/25, an interview was conducted with the representative of Resident #84.

During the interview, the representative stated when he visits the facility it is hard to find staff when help is needed. He stated Resident #84 ' s room smelled strongly of urine when he visited recently. He stated Resident #84 had soiled her brief and eventually removed it, and staff did not come in to change her or remove the brief from the room, leaving it to smell like urine. He stated I know they are doing the best they can up there with the staff they have, but they need more. That ' s my only complaint is that you can ' t find help when you need it.

On 04/14/25 at approximately 2:00PM a Resident Council Meeting was held. During the meeting, the residents brought the following issues forward, related to staffing.

-Residents reported a lot of times only one staff person per hall - especially North-short Hall and South-long Hall.

-Wait on call lights for one (1) to one (1) and a half hours - sometimes it could take up to 3 hours to get assistance.

-One person to 16 rooms at night.

-A lot of call offs from staff.

-Nurses and CNAs are afraid of how long they will have to stay because of call-offs or not enough staff scheduled.

H) Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 At approximately 10:15 PM on 4/14/25 an interview was conducted with Nurse Aide (NA) #21. NA #21 stated there is a call-in problem with some employees. She stated this leaves the staff in a position where someone Level of Harm - Minimal harm or is working over, and sometimes they can ' t get the shift covered. She states this leaves them working short potential for actual harm frequently. She states she feels the residents do not receive the care they need due to staffing issues.

Residents Affected - Many At approximately 10:35 on 4/14/25, on the North side of the facility, multiple call lights were observed going off on the long hallway. NA #15 was answering lights in the hallway, and the administrator was observed answering another. Lights continued to go off on the long hallway. At this time, NA #13 and #21 were observed standing in the back, short, hallway, leaned against the wall, talking, not responding to the call lights, despite no call lights ringing on the back, short, hallway.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress Level of Harm - Minimal harm or disorder. potential for actual harm 51554 Residents Affected - Few Based upon record review and staff interview, the facility failed to ensure resident received mental health referral and treatment. This was true for 1 (one) of 38 (thirty-eight) residents reviewed during this annual survey process. Resident identifier: #110. Facility census: 111

Findings included:

A) Resident #110

A review of Resident #110's medical record found the following:

Diagnosis Included:

Post traumatic stress disorder

Anxiety Disorder

Depression

A review of the MDS quarterly assessment on 04/03/25, recorded the following:

Section D - Mood

D0160: Total severity score of 18

D0170 Social Isolation was marked as always feeling lonely or isolated from those around you.

Section E - Behavior

Verbal behaviors towards others

occuring 4 - 5 days per week

Section I - Active Diagnoses

Psychiatric/Mood Disorder:

Anxiety Disorder

Depression

Post Traumatic Stress Disorder

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 The most recent PASARR: Was completed on 02/04/25 by (Name of Local Hospital) and contained the following: Level of Harm - Minimal harm or potential for actual harm Q23 Medical conditions/symptoms:

Residents Affected - Few Mental disorders None

Section III: MI/MR Assessment

Current diagnosis: None is marked

Section IV: Assessment/Plan

Suspect patient has underlying dementia now with stroke-likely exacerbated does not have insight to her own medical condition since does not have medical decision-making capacity.

Section V: Supplemental Questions

Major Mental Illness or suspected mental illness: none

Level I (Medical Screen

Diagnosis of dementia (Alzheimer's or related condition): box next to question is not checked, indicating the resident does not have this.

Resident #110 had the following physician orders:

Dental, ophthalmology, podiatry, physiatry, psych,wound Obtain Consult as needed/indicated and treatment for patient health and comfort.

No directions specified for order.

Other Active 2/5/2025

Resident is not prescribed any anti-psychotic, anti-depressant, or anti-anxiety medications.

A review of Resident #110's care plan found the following:

Focus area:

Resident/patient exhibits or has the potential to demonstrate verbal behaviors related to history of making false accusations regarding staff and other residents relating to this resident's cognitive impairment, confusion, and desire to return home/not be in long-termcare environment. Date initiated: 02/26/25

Interventions included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Evaluate the nature and circumstances (i.e. triggers) of the {verbal behavior} with resident and/or patient reresentative. Level of Harm - Minimal harm or potential for actual harm Evaluate need/provide for Psych/Behavioral Health consultation.

Residents Affected - Few The resident's medical record contained a Meditelecare behavior health signed Authorization to Screen, Evaluate & Treat signed by the resident on 2/6/25.

The Surveyor requested to see any screenings, evaluations, progress notes on the resident for services provided by Meditelecare.

B) Staff interview

On 4/16/25, after asking for documentation related to any Meditelecare screenings or visits for the third time,

the Director of Nursing stated at 6:02 PM there were no progress notes, evaluations, etc from Meditelecare.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 31826

Residents Affected - Few Based on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled to enable them to identify and correct any possible drug diversions. There were some discrepancies related to Resident #97's controlled substance log. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #97. Facility Census: 111.

Findings Include:

a) Resident #97

A review of Resident #87's medical record on the morning of 04/16/25 found the resident was ordered Hydrocodone 5-325 by mouth every 6 hours for pain,

The medication administration record for the month of 03/2025 and the month of 04/2025 along with the controlled substance log coinciding with these months was requested.

Upon review of the MAR and the controlled substance log it was found on 03/21/25, a nurse signed out one (1) dose of the Hydrocodone, but it was not initialed as given on the MAR. Also, between the 6:00 am dose of Hydrocodone on 03/30/325 and the 12:00 PM dose on 03/31/25 two (2) hydrocodone pills were removed and deducted from the count. However, the nurse did not sign, date or time the withdrawals on the controlled substance log as required.

This was confirmed with Corporate Registered Nurse (CRN) #132 at 5:00 PM on 04/16/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 31826

Residents Affected - Few 50795

Based on record review, and interview, the facility failed to ensure the attending physician reviewed and acted on the Consulting Pharmacist's recommendations. In addition, the facility failed to ensure that the physician reviewed and documented a response to the recommendations. This was true for five (5) of five (5) residents surveyed. Resident Identifier: Resident #17, # 28, #53, #74 and #87. Facility Census: 111.

Findings include:

a) Resident #17

On 04/14/25 at 3:11 PM a review of the Consulting Pharmacist's review for Resident #17's medications revealed the following:

The Consulting Pharmacist's medication review on 09/20/24 showed the following recommendations:

Resident is on Quetiapine 25 MG at bedtime for muscle weakness.

This is not an appropriate diagnosis.

Recommendation:

An antipsychotic medication should be used only for the following conditions/diagnoses. Please check the appropriate indication for this resident:

Huntington Disease

Mood disorders (e.g. bipolar disorder, severe depression refractory to other therapies and/or with psychotic features)

Medical illnesses with psychotic symptoms (e.g. neoplastic disease or delirium) and/or treatment related psychosis or mania (e.g. High dose steroids)

Nausea and vomiting associated with cancer or chemotherapy

Schizophrenia

Schizo-affective disorder

Schizophreniform disorder

Psychosis in the absence of dementia

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Tourette's disorder

Level of Harm - Minimal harm or Other potential for actual harm Facility failed to ensure that the physician reviewed and responded to the recommendation. Residents Affected - Few DON provided an updated diagnosis dated 04/05/25 which stated - Quetiapine Fumarate Oral tablet 25 MG. Give 0.5 tablet by mouth at bedtime for targeted behaviors - agitation, verbal outbursts.

The Consulting Pharmacist's medication review on 10/23/24 revealed the following recommendation:

Please update the current antipsychotic order for Quetiapine 12.5 MG at bedtime with a diagnosis and include specific behaviors that can be quantitatively and objectively documented by the nursing staff. The behavior must have the potential to cause danger to themselves and/or others.

The facility failed to ensure that the physician reviewed and acted upon the recommendation.

The Consulting Pharmacist's medication review on 12/18/24 showed the following recommendation:

This resident is on the anticoagulant Rivaroxaban Oral tablet 15 MG. Anticoagulants have an inherent increased risk for bleeding and potential for thromboembolism.

Please add order to monitor for signs and symptoms of bleeding and thromboembolism during each nursing shift. Notify prescriber if resident experiences any of the following signs/symptoms of bleeding, dark/discolored urine, black tarry stools. Nose bleeds, vomiting and/or coughing up blood.

Signs/symptoms of thromboembolism:

Pain or tenderness of upper or lower extremity. Increased warmth, edema and/or erythema of affected extremity. Unexplained shortness of breath. Chest pain, coughing, Hemoptysis, feelings of anxiety or dread.

The facility failed to ensure that the physician reviewed and acknowledged the recommendation.

b) Resident #28

On 04/14/25 at 3:25 PM a review of the Consulting Pharmacist's review for Resident #28's medications revealed the following:

The Consulting Pharmacist's medication review on 12/17/24 showed the following recommendation:

The resident is on the anticoagulant Eliquis. Anticoagulants have an inherent increased risk for bleeding and potential for thromboembolism.

Please add order to monitor for signs and symptoms of bleeding and thromboembolism during each nursing shift. Notify prescriber if resident experiences any of the following signs/symptoms of bleeding, dark/discolored urine, black tarry stools. Nose bleeds, vomiting and/or coughing up blood.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Signs/symptoms of thromboembolism:

Level of Harm - Minimal harm or Pain or tenderness of upper or lower extremity. Increased warmth, edema and/or erythema of affected potential for actual harm extremity. Unexplained shortness of breath. Chest pain, coughing, Hemoptysis, feelings of anxiety or dread.

Residents Affected - Few The facility failed to ensure that the physician reviewed and acknowledged the recommendation.

c) Resident #53

On 04/14/25 at 3:35 PM a review of the Consulting Pharmacist's review for Resident #28's medications revealed the following:

The Consulting Pharmacist's medication review on 01/14/25 showed the following recommendation:

Please record specific behavior seen and any side effects with use of the psychoactive medication Buspar. If side effects are seen, physician should be notified. Please record behavior even if dose of medication is not given.

Add MAR behavior monitoring for Buspar.

The facility failed to ensure that physician reviewed and acknowledged recommendations.

d) Resident #74

The Consulting Pharmacist's medication review completed on 01/20/25 showed the following recommendation:

Please add a behavior monitoring sheet for this resident due to Duloxetine.

Record specific behaviors and any side effects noted with use of psychoactive medications given. If side effects are noted, physician should be notified. Record all behaviors noted, even if medication is not given as

the intervention.

The facility failed to ensure that the physician reviewed and acknowledged the recommendation.

During an interview on 04/15/25 at 2:30 PM the Director of Nursing (DON) confirmed that the physician had not signed the Pharmacist's recommendations

e) Resident #87

A review of Resident #87's medical record on the morning of 04/16/25 found the pharmacist reviewed the resident's drug regimen in 02/2025 and 01/2025 and made recommendations to the physician and/or Director of Nursing (DON).

The recommendations were requested from the facility along with the physicians and/or DON's response.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 At 5;22 PM on 04/16/25 the Corporate Registered Nurse (CRN) #132 confirmed they could not locate the recommendations nor the physician and/or DON response. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 31826

Residents Affected - Some Based on observation and staff interview the facility failed to ensure each resident received the proper portion size of pork during the evening meal on 04/16/25. This failed practice has the potential to affect more than an isolated number of residents and was random opportunity for discovery found during the completion of the kitchen pathway during the long-term care survey process. Facility Census: 111.

Findings Include:

On 04/16/25 at 5:32 PM the surveyor was observing meal service from the steam table in the facility's kitchen. [NAME] #130 was serving the food from the steam table. She was observed using tongs to serve the pork.

The Director of Operations (DOO) was asked how she was sure the pork she was serving was two ounces (OZ) she stated she should be using a 2 oz scoop and not tongs. She corrected the situation; however, the North Short Hall and the South Short Hall had already been served.

A review of the menu found each resident should be served 2 ounces of pork.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 31826 Residents Affected - Some Based on observation and staff interview the facility failed to ensure all residents received meals at regular times comparable to normal mealtimes in the community. The lunch meal on 06/04/25 was served 45 minutes late to 19 residents due to the facility running out of prepared food. This was true for Resident #95, #3, #68, #60, #90, #21, #29, #24, #56, #6, #61, #5, #41, #79, #38, #58, #36, #45, and #49. Facility Census: 101

Findings Include:

a) An observation of the lunch meal began at 12:00 PM on 06/04/25 found the facility was serving ham, macaroni and cheese and beets as the main meal for the residents. At 1:10 PM [NAME] #1 stated, I ran out of food. I'm going to have to make more. The Corporate Director of Operations then began preparing and directing the staff on what to make to continue to the feed the remaining 18 residents. The Corporate Director of Operations, indicated they did not know what happened. They said they made more than the production sheet called for but was still short on servings.

The final resident was served at 1:56 PM on 06/04/25 which was 46 minutes after the facility initially ran out of food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 50795

Residents Affected - Few Based on observation, record review and interview, the facility failed to update orders to discontinue dialysis access care, and monitoring of the dialysis access graft/fistula. In addition, the facility failed to update orders and a care plan when a C-collar was discontinued. Resident Identifiers: #88, and #10. Facility Census: 111.

Findings Include;

a) Resident #88

During an interview, on 04/15/25 at approximately 1:20 PM, Resident #88 stated the dialysis access in her right upper arm was no longer patent.

The resident stated he now had a dialysis catheter in her right upper chest, which was used during hemodialysis treatments.

Record review on 04/15/25 at approximately 2:15 PM revealed the following order dated 10/08/24:

External hemodialysis catheter 2 lumens (location) right chest wall with transparent dressing. DO NOT Change END caps.

Further record review revealed the following orders dated 08/31/24:

AV fistula/graft location: right upper extremity

Change AV fistula/graft site dressing every Thursday

Monitor AV fistula/graft site for S/S infection, edema, bleeding and upon return from dialysis. Notify primary care physician and dialysis unit if there are signs and symptoms of infection If AV fistula/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician extender if bleeding does not stop

Auscultate bruit and palpate thrill. Notify physician for absence of bruit/thrill. Every day and night shift.

A review of the Treatment Administration Record (TAR) on 04/15/25 at 3:30 PM revealed facility staff continued to monitor the non-patent dialysis access, and document it was working.

Monitoring was discontinued after surveyor intervention on 04/15/25 as evidenced by the following documentation:

Auscultate bruit and palpate thrill. Notify physician for absence of bruit/thrill.

every day and night shift

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Start Date-

Level of Harm - Minimal harm or 08/31/2024 1900 potential for actual harm D/C Date- Residents Affected - Few 04/16/25 1047

Monitor AV fistula/graft site for S/S infection, edema, bleeding and upon return from dialysis. Notify primary care physician and dialysis unit if there are

signs and symptoms of infection. If AV fistula/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician extender if bleeding does not stop as needed

Start Date-

08/31/2024 1549

D/C Date-

04/16/25 1045

During an interview with Unit Manager (UM) #97 on 04/15/25 at 3:26 PM, UM #97 confirmed the access was still being monitored. She stated she would discontinue the orders for monitoring.

51553

b) Resident #10

The facility failed to update orders and care plan for Resident #10's C-collar which was discontinued on 04/09/25 as recorded on the resident's Medication Administration Record (MAR).

Resident #10's physician's order stated, Skin integrity checks; monitor c- collar placement and surrounding skin q shift to for skin integrity checks; notify provider for any abnormalities or concerns every day and night shift.

The care plan stated: c-collar to be in place to assist with healing and protection as resident will allow.

On 04/14/25, nurse's progress note stated, Resident refusing C-Collar. Patches not needed at this time.

On 04/15/25 at 12:47 PM, the Director of Nursing confirmed the discharge order for the c-collar and the order for skin checks and care plan were not updated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 59 515087 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515087 B. Wing 04/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Ridge Center 302 Cedar Ridge Road Sissonville, WV 25320

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50795 potential for actual harm Based on observation and interview, the facility failed to ensure infection control procedures were adhered to Residents Affected - Some in the residents' shower room. This failed practice had the potential for infection of a limited number of residents. This was true for one (1) of two (2) shower rooms inspected during the survey process. Facility Census: 111.

Findings included:

a) During an inspection of the male and female shower rooms, accompanied by Licensed Practical Nurse (LPN) #26 on 04/14/25 at approximately 1:20 PM, five bottles of unlabeled shampoo bottles were observed

in the male shower room. LPN #26 confirmed the bottles of shampoo were not labeled with any resident names.

On 04/14/25 at approximately 2:30 PM, the Director of Nursing (DON) confirmed all unlabeled shampoo bottles had been removed from the shower room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 59 515087