Cedar Ridge Center

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Oxycodone placed on logbook to be destroyed on 07/09/25Resident #4 - 22 Hydrocodone placed on logbook to be destroyed on 07/14/25Resident #5 - 22 Hydrocodone/Norco placed on logbook to be destroyed on 07/14/25Resident #6 - 9 Hydrocodone placed on logbook to be destroyed on 07/14/25Resident #7 - 28 Hydrocodone placed on logbook to be destroyed on 07/29/25Resident #8 - 27 Hydrocodone placed on logbook to be destroyed on 07/29/25Resident #9 - 15 Oxycodone placed on logbook to be destroyed on 07/29/25When the Pharmacist arrived at the facility on 08/15/25 to destroy the appropriate medications that were logged in the book and located in the lock box, the above narcotics were missing. The allegation of misappropriation was reported to the appropriate facilities, including law enforcement. The allegation of drug diversion and misappropriation was substantiated, however it was undetermined how or when the medications were taken or by who.c) Resident #10On 10/15/25 at 10:23 AM record review of a reportable facility incident revealed that on 10/09/25 at 7:00 AM there was a discrepancy of the medication count of seven (7) 7.5-200 mg Hydrocodone tablets. The allegation of misappropriation was reported to the appropriate facilities, including law enforcement. An investigation was initiated, and the resident was interviewed as well as the staff. Resident #10 denied any previous missing doses of her pain medication. She has a BIMS of 15 and has capacity as per the Physicians Determination of Capacity.During the investigation it was determined that the Licensed Practical Nurse (LPN) was on duty from 7:00 PM until 6:00 AM on 10/08/25 had counted the medications and recorded the manifest with another LPN as her 2nd witness. There were no discrepancies noted at that time. On 10/09/25 at 6:00 AM LPN #7 relieved the LPN for one (1) hour. She had keys to the medication cart. At 7:00 AM on 10/09/25 when the oncoming nurse reported, LPN #7 did not wish to recount the medications. The oncoming nurse obtained additional staff to do the count, and it was noted at that time that the 7 Hydrocodone tablets were missing.The facility notified the medical provider and obtained the appropriate pain medication the resident needed to keep his pain in control. An investigation was conducted into the allegation of misappropriation including drug diversion and was substantiated. It was identified that LPN #7 was responsible. The nurse was terminated from the facility, and the diversion was reported to the [NAME] Virginia Licensed Practical Nursing Board, and a Drug Enforcement Agency (DEA) form has been sent to the respected agency.The Policy for Management of Controlled Drugs #NSG300 explained procedure for ordering, receiving, storage, ongoing inventory, returns, destruction, and emergency supplies with the purpose to minimize the opportunity for theft or diversion of controlled substances.The Shift-to-Shift Medication Administration Controlled Substances Section 7.4 under Policy stated, At each shift change, a physical inventory of controlled medications, as defined by state regulation, is conducted by two licensed clinicians and is documented on an audit record. It further stated, Controlled Substances remaining in the nursing care center after the order has been discontinued are retained in the nursing area center in a securely double locked area with restricted access until destroyed, as outlined in state regulation.The above findings were confirmed with the Administrator, Director of Nursing and the Corporate Resource Nurse on 10/16/25 at 11:15 AM at which time they agreed the narcotics were part of a drug diversion, misappropriation of personal property.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview the facility failed to complete all Physicians orders for wound treatment.

This was true for one (1) of three (3) residents reviewed during this investigation. Resident Identifier: #1 Facility Census: #112 Findings Include:a) Resident #1On 10/16/25 at 9:10 AM record review of Resident #1 orders and Treatment Administration Records (TAR) for August, September and October 2025 found missing documentation as shown below. All orders and TAR's were reviewed for the period of 08/01/25 10/31/25. None of the following Physician orders were completed on 10/09/25, 10/16/25, 10/21/25 or 10/22/25.Clean DTI (deep tissue injury) to left buttocks with wound cleaner, pat dry, apply skin prep to area and leave open to air every day shift.Clean left outer foot (amputation site) with wound cleaner, pat dry, apply Betadine and leave open to air every day shiftClean venous ulcer to left dorsum 1st digit (hallux) with wound cleaner, pat dry, apply Betadine and leave open to air every day shift.Clean venous ulcer to right dorsum foot with wound cleaner, pat dry, apply Betadine and leave open to air every day shift.Clean venous ulcer to top of left foot with wound cleaner, pat dry, apply Betadine and leave open to air every day shift.

None of the following Physician orders were completed on 10/08/25 or 10/10/25Cleanse abrasion to left elbow with wound cleanser. [NAME] dry and apply skin-prep to area and surrounding area. Leave open to air every day shift.Cleanse abrasion to left shin with wound cleanser, pat dry, apply sureprep and leave open to air every day shift.Cleanse diabetic wound to right lateral foot with wound cleanser, pat dry, paint with betadine and leave open to air every day shift.Cleanser stage 2 to sacrum with Vashe wound cleanser, pat dry, sure prep to periwound. Apply silicone barrier cream to wound cover with foam dressing every day shiftCleanse stage 2 to sacrum with Vashe wound cleanser, pat dry, sure prep to periwound, apply silicone barrier cream to wound, place fulffed xerofoam between buttock proximal of upper annus to prevent soiling of wound every day shift.Cleanse venous to left dorsum 1st digit (hallux) with wound cleanser, pat dry, paint with betadine and leave open to air every day shift.Cleanse venous to left dorsum 1st digit with wound cleanser, pat dry paint with betadine and leave open to air every day shift.Cleanse venous to left dorsum 3rd digit with wound cleanser, pat dry, paint with betadine and leave open to air every day shift.Cleanser venous to left dorsum 4th digit with wound cleanser, pat dry, paint with betadine, leave open to air every day shift.Cleanse venous to left medial foot with wound cleanser, pat dry, paint with betadine and leave open to air every day shift.Cleanse venous to right dorsum foot with wound cleanser, pat dry, paint with betadine and leve open to air every day shift.All of the above findings were confirmed with the Corporate Resource Nurse and the Administrator on 10/16/25 at 11:00 AM at which time they agreed the wound treatment was not completed as ordered by the Physician.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet