Cedar Mountain Post Acute

In the surveyor’s words

From the most serious findings on record at Cedar Mountain Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 10, 2022

  Based on observation, interview, and record review, the facility failed to provide supervision to one of 88 residents (Resident 1) on October 3, 2022, when the resident was left unattended by staff while on the facility ' s smoking patio which had an unlocked, unalarmed, and unmonitored access gate. Resident 1 had a diagnosis of Alzheimer ' s disease (a progressive disease affecting the memory and function of the brain) and had been identified by the facility as a high risk for elopement (leaving the premises or safe area without authorization or supervision to do so). […]

• No harm, potential for more than minimal, patternF812Mar 16, 2023

  Based 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. Findings: During a concurrent observation and interview with the Kitchen Cook (KC 1) on March 13, 2023, at 8:35 AM, there were food debris, black grime and dirt seen under the kitchen stove and griddle. […]

• No harm, potential for more than minimal, isolatedF726Aug 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure that one of four Certified Nursing Assistants (CNA 1) knew how to respond effectively in the event of a power outage affecting residents who were dependent on ventilators (machine to assist residents who are too sick, weak, or injured to breathe well on their own). This failure posed a significant risk to the lives of fourteen clinically compromised residents who were on ventilators due to their clinical condition.Findings:During a concurrent observation and interview on July 22, 2026, at 1:30 PM, with the Respiratory Supervisor (Supervisor) and the Maintenance Director (Director), a tour of the subacute care unit (a transitional inpatient facility providing goal-oriented, specialized medical and… […]

• No harm, potential for more than minimal, isolatedF689Apr 21, 2026

  Based 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). […]

• No harm, potential for more than minimal, isolatedF676Jan 16, 2026

  Based 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,… […]