Following an unannounced complaint investigation survey, the Centers for Medicare and Medicaid Services (CMS) cited Cedar Ridge for deficiencies related to its provision of nursing care, as well as failures in upholding patient’s rights to care in a safe setting and to freedom from abuse and harassment. The deficiencies related to an allegation of sexual abuse of a patient by a staff member. CMS found that Cedar Ridge assigned the male staff member to monitor a female patient on two consecutive days, even though facility policy requires “same sex staff [to] monitor” patients during times of sleeping, restroom use, and showering. Additionally, the facility’s staffing sheets showed the hospital had the coverage to allow a female staff member to provide 1:1 observation of the patient on one of the shifts, but failed to do so. The patient later reported to nursing staff that the male staff member touched her inappropriately and had sexual contact with her. CMS found that the hospital did not investigate this allegation, noting, “The material did not contain interviews with other staff and patients present on the unit at the time of the alleged occurrence, including Patient #1’s roommate and the alleged perpetrator.” CMS also found that, “documents provided did not demonstrate the hospital had developed and instituted corrective actions to ensure staff and patients would not be placed in this compromising situation again.” The CMS survey team reported that two staff members spent 9 hours at the facility performing the survey, and an additional 5-7 hours each in compiling their report.