Cedar Mountain Post Acute

Inspectors wroteBased on interview and record review, the facility failed to implement their own policy regarding safety and supervision for one of three sampled residents (Resident 1) when Resident 1 had a fall incident during a transfer to a shower chair on March 14, 2026. This failure may have potentially contributed to Resident 1 sustaining acute mildly displaced fracture of the proximal tibia and proximal fibular shaft (a recent break in the upper neck of the knee and the thin shin bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services, which were consistent with the resident's needs and choices, for residents who are unable to carry out Activities of Daily Living (those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) independently for one of three sampled residents (Resident 1) when Resident 1, who was dependent for self-care and mobility, was repositioned by a Certified Nursing Assistant (CNA 1) in bed by himself, dishonoring Resident 1's Wife's preference for Resident 1 for a two-person assist (safe patient handling technique in healthcare where two trained caregivers help someone move, transfer, or perform daily activities when they can't do it alone). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment for one of four sampled residents (Resident 12) when the Minimum Data Set (MDS- a standardized assessment tool) assessment did not reflect the accurate status of Resident 12 who was receiving hospice (end of life care) services. This failure had the potential for unmet services necessary for Resident 12's hospice care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive and person-centered care plans for one of one sampled resident (Resident 25) when:a. There was no care plan addressing anticoagulant (medication that helps prevent blood clots) use for Resident 25.b. The facility did not implement injury prevention interventions identified in Resident 25's fall risk care plan. These failures had the potential to result in complications from anticoagulant therapy and injury from falls for Resident 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 17, Resident 22, and Resident 25) were free from accident hazards when:a. The wheelchair arm rests for Resident 22 were peeled off with abrasive fragments and exposed cushion.b. Floor mats were not provided as ordered for injury prevention interventions for Resident 17. c. Floor mats were not provided as ordered for injury prevention interventions for Resident 25. These failures had the potential to compromise the safety of Residents 22, 17, and 25 and result in skin breakdown, accidents, and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental services, including the timely provision and replacement of dentures, were provided to one of one sampled resident (Resident 84). This failure had the potential to result in impaired nutrition, oral pain and discomfort, difficulty eating, and decreased quality of life for Resident 84.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices to provide a safe and sanitary environment to help prevent the transmission of spreadable diseases and infections when:1. One gray basin was found on the bathroom floor containing four food containers and two utensils.2. Respiratory Therapist 1 (RT 1) did not do hand hygiene after stepping out from Resident 58's room and after removing gloves.3. Three resident trash bins were full and overflowing. These deficient practices posed the risk for transmission of communicable diseases and infections to residents in the facility.

Inspectors wroteBased on interview, and record review the facility staff failed to notify the physician for one of three sampled residents (Resident 2) when: 1. Resident 2 had twenty-four episodes of high blood pressure (blood pressure higher than 160) and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications. 2. Resident 2 had eight episodes of high blood sugars and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illnesses as evidenced by food debris, black grime and dirt were observed under the kitchen stove and griddle. This failure had the potential to result in food contamination and foodborne illnesses to medically compromised population of 71 of 94 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the status of a pressure injury (a wound developed on bony prominences as a result of prolonged pressure) in the Minimum Data Set (MDS - a computerized clinical assessment) for Resident 31. This failure had the potential to inaccurately reflect Resident 31's status to the oversight agency (Center for Medicare and Medicaid Services - CMS), who provides funding for Resident 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to submit an updated Preadmission Screening and Resident Review (PASRR - a federal screening requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) after a diagnosis of Schizophrenia (a serious mental illness that affects how a person think, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations) had been identified after admission for Resident 78. This failure had the potential for Resident 78 not to be accurately assessed by a qualified mental health professional, in order to ensure proper placement related to his mental illness.

Inspectors wroteBased on interview and record review, the facility failed to identify mental disorders during the Preadmission Screening and Resident Review (PASARR-a screening to identify the presence of serious mental illness) for one of one sampled resident (Resident 61). This failure had the potential to cause Resident 61 not to receive specialized mental health services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to maintain and improve one of one sampled resident (Resident 36) ability to communicate her needs to the facility staff. This failure had the potential to cause Resident 36's needs to go unmet resulting in frustration, pain, and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 36) was repositioned every two hours to promote healing of Resident 36's Stage IV pressure sore (an injury caused by prolonged pressure that is very deep, reaching into muscle and bone). This failure had the potential to cause Resident 36's Stage IV pressure sore to worsen or additional pressure sores to develop.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide adequate supervision and a valid assistance device (fire extinguisher) to prevent accidents when: 1. Resident 50 was found smoking on the outside patio without one-to-one supervision. This failure had the potential for Resident 50 to have a smoking accident. 2. A fire extinguisher's inspection tag had expired, and the fire extinguisher was mounted in the smoking area for use. This failure had the potential for residents to be exposed to injuries for outdated equipment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide the necessary respiratory care when a Physicians order for Oxygen therapy was not followed for one of three residents (Resident 59). This failure had the potential for resident 59 to experience shortness of breath.

Inspectors wrote2. During a review of Resident 78's clinical record, the face sheet (contains admission and demographic information) indicated Resident 78 was admitted on [DATE], with current diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations). Further review of the clinical record indicated the resident had a current physician's order for Seroquel Oral Tablet 50 mg [milligram - unit of measurement] .Give 1 tablet by mouth two times a day for schizophrenia m/b [manifested by] auditory hallucinations . During a concurrent observation and interview on March 13, 2023, at 8:22 AM, Resident 78 was observed lying in bed, mumbling, and talking to himself. No one else was at his bedside at the time. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor antipsychotic medication for effectiveness and adverse [harmful] side effects for one of one sampled resident (Resident 12). This failure had the potential to cause ineffective control of symptoms to go unrecognized and unaddressed. In addition, Resident 12 had the potential to suffer prolonged adverse side effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist with dental services needed for one of six sampled residents (Resident 196). This failure prevented Resident 196 from obtaining an identified need for dental services.

Inspectors wroteBased on observation, interview and record review, the facility failed to practice infection prevention and control in accordance with their policy for one of six sampled residents (Resident 73) when a foley catheter (a flexible tube that a clinician passes through the bladder) drainage bag was observed touching the floor. This failure had the potential to cause catheter-associated complications including urinary tract infection for Resident 73.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an opened bag of carrots in the walk-in refrigerator was dated, labeled, and sealed. This failure had the potential to cause food-borne illnesses for 86 out of 88 residents in the facility who received food from the kitchen and were a medically vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan for one of one sampled resident (Resident 11) to address repeated non-compliance with the facility's smoking policy. This failure had the potential to result in Resident 11 placing herself, other residents and staff at risk of injury from a possible fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to address one of one sampled resident (Resident 11) repeated non-compliance with the facility's smoking policy. This failure resulted in a risk of fire and had the potential to put residents and staff at risk for harm.